HomeMy WebLinkAboutG-14-1047 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'ale CRY - ! Qt -Fv1 p( �. _ MA DATE __01/2//'7J,PERMIT# big'/Orf
G OWNER ADDRESS 3 a'Wks iv ill
Rip IOWNER'SNAME GtC&i RA
JOBSITE ADDRESS_
TEL FAX _j
TYPE OR OCCUPANCY TYPE COMMERCIAL J EDUCATIONAL`J RESIDENTIAL J
PRINT
CLEARLY NEW: J RENOVATION: REPLACEMENT:`J PLANS SUBMITTED: YES J NO J
APPLIANCES 1 FLOORS-. BSM 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 I
GRILLE -
INFRARED HEATER •
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER •
ROOF TOP UNIT
TEST I
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER •
OTHER
INSURANCE COVERAGE
I have a Cufrent liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES (LI NO J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -
LIABILITYINSURANCEPOLICY +1 OTHER TYPE INDEMNITY j. BOND HJ
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 'Ji AGENT ;J
SIGNATURE OF OWNER OR AGENT •
I hereby certify that all of the details and Information I have submitted or entered regarding this application are this and accu - =ato a best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In complian' ;'th : i -.nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ;`•
PLUMBER-GASFITTER NAME• ken duarte I LICENSE# 11012 j / SIGNATURE
MP _+J MGF JP J JGF J LPG!J CORPORATION_'j# 3541 I PARTNERSHIP_..I# _j LLC'J# j
COMPANY NAME duarte plumbing km I ADDRESS 37 collins ave
CITY centerville — ..
STATE ma I ZIP 02632 jT L 50&250-2763j
FAX 508-775.9135 J CELL [EMAIL kenduarte37@hotmail.com JUN 13 261vigt1
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Sa.LON M3IA3l NV7d
#111/013d $ :334
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