HomeMy WebLinkAboutG-14-712 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITI ING WORK.
CITY: w y144#wQurK MA DATE //23/a/vPERMIT# Nil--7�Z.
`' JOBSrrE ADDRESS - %Q !✓7('61�J C,+oewt2L OWNER'S NAME /664 I/ CKsxnl.r.F
q Q G OWNER,ADDRESS:_ �/ TEI_JaY17,r 53/1 FAX
� TYPE OR OCCUPANCY TYPE COMMERCIAL LvJ EDUCATIONAL. 0 RESIDENTIAL 0
PRINT ^/
CLEARLY NEW:0 RENOVATION:EV REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 12/
APPLIANCES? FLOOR Bsrt 1 1 1 2 1 3 1 4 1 5 B 7 1 8 9 10 11 12 13 1 14
BOILER I I I I
BOOSTER
I CONVERSION BURNER
I
COOK STOVE I I I I _I
DIRECT VENT HEATER j I
DRYER I
FIREPLACE I I
FRYOLATOR I I I I
FURNACE I I
GENERATOR II
GRILLE I I
INFRARED HEATER I I
LABORATORY COCK
I
MAKEUP AIR UNIT I I I I I I
OVEN I I
POOL HEATER I I '
ROOM/SPACE HEATED, I I I I I �_ i
I ROOF TOP UNIT I I I
TEST I / I I I I I I I
UNIT HEATER I
I UNVEN ED ROOM HEATER I I I
WATER HEATER I I I I I
II I I I I I
I I I I I I I I I I I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL at 142 YES NO 0
Ifyou have checked YES,please indicate the type of coverage y checking the appropriate box below.
UABIUTY INSURANCE POLICY 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'•. . accura to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application '111 e in gym';1 -- -t'.. - t
provision of the Massachusetts State Plumbing Code andndChapter 142 of the General Laws. /
PLUMBERJGASFI I I tkNAME ���n/l�i` cJ - /C °ff LICENSE#1617 �I SIGNATU-
COMPANY NAME: o i J /' , ' i ADDRESS:
CITY: 1.W.)41-401007-71 . �A STATE flu LP: 02473 FAX:
Ta: <61/-771- (icy/GELL:say-36 7- Wiy EMAIL: i Ana _ Ile C c.®
MASTER[Si JOURNEYMAN❑ LP INSTALLER 0 CORPORATION 0 it Pr 1 'ig2541P I]4--`7-1 LG❑
JAN 23 21Cii'1 11
_ ARTM��4" Opt'
MEG •
IGAS YE '_ •N ► ' . pus PAGLI+oKIINSYICCI'OBUSLONLY VENIAL INSmen oN NOTES
R6Ir 6,49 en eat / '1 / Yos No
THIS APPLICATION SERVES AS TI IE PERMIT ❑ 0
FEE: $ PERMITQ
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