HomeMy WebLinkAboutG-14-1054 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL Q RESIDENTIAL.{'
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CLEARLY NEW:Q RENOVATION:[ REPLACEMENT:[CO PLANS SUBMITTED: YES❑ NOQ
APPLIANCES I FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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DIRECT VENT HEATER ma Ina SalloWINE intinisi— _a
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GENERATOR IM1.11M,1111111)11101011 M1•a aantS
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INSURANCE COVERAGE
I h, e a, currYLinsurancepolicy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES k NO Q
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [X OTHER TYPE INDEMNITY Q BOND Q
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 Q AGENT Q
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Intonation I have submitted or entered regarding this application are t 9 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 co •l'ance with al Perti provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I../ 41/2..p— l",,nl rri A I LICENSE#','WI / SIGNATURE
MP12a_MGF Q JP Q JGF Q LP I Q CORPORATION[, ( /0//el PARTNry: IP Q# LLC Q#
COMPANY NAME: (,,rrrC tum(O,h (, ADDRESS / WC tfIr1cr-}-O✓I 7,yZa
CITY 1 7/lro/l1 'U STATE 2T ZIP OZ Es-4pSqo
TEL 1- 4239- 2/fill
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FAX CELL ,EMAIL PIO) 1Afy\ C,ern 0tct
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ROUGH CAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT R
PLAN REVIEW NOTES