HomeMy WebLinkAboutG-14-455 II
N •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: &Vflt YARHWTH MA. DATE: PERMIT#`T/11- 4s
JOBSITE ADDRESS: c-,740 MARVA9b St OWNER'S NAME: BPJAAJ 1MAJTHROL1/
GOWNER ADDRESS: TEL: FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:9 PLANS SUBMITTED: YES❑ NO 0
APPLIANCES? FLOOR-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE /
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HCATCR ( -
-RtutiVED
3910- 0601 4c4N.
NOV 5 2013
INSURANCE COVERAGE Pt Pito ,,.,/
I lave a current is•'lity insararce policy or its substantial equivalent which meets the requirements of MGL.Ch BIM NO ❑
BUILDING 4Iji-,( TMENT
d y. •. �, .Qd YES,please indicate the type of coverageagby checking the appropriate box below.
_
LIABILITY INSURANCE POLICY L� OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
•
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian �''ith a 'er'nent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. --
d
aws. d
! ri/
PLUMBER/GASFITTER NAME:Tl'L01UY E. 5U14 VAIJ LICENSE# ta5r& SIGNA R
COMPANY NAME: T. soul vAN PeZ/IAJMAl— ADDRESS: /10A /(ANOU ST, (J,viTA
CITY: /-1AMottEJ - STATE: MA ZIP: 0339 FAX: 767-el/;52499
TEL: 79/-8.17P rn CELL: 101'7-6-93 'c159 - EMAIL: -7-5(4/Ygeh,COOOmC,ST,/K-7
MASTER JOURNEYMAN LP INSTALLER 0 CORPORATION Ere cV10,-,2 PARTNERSHIP 0# LLC❑#