HomeMy WebLinkAboutG-14-787 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITIING WORK
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w?_=t G1': LIayr.ovtl_ MA DATE Z/1911/ PERMIT' 6/1 --777
oJOBSITE ADDRESS' 33 I Eow e s (2c( OWNERS NAME .Da v id lie +
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>, 1� L fAU l OWNER ADDRESS: TEL' FAX
>P OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALI
0t m � 7' NEW[y RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
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L1.1 W AP? IANCES1 FLOOR—+ Bscrt 1 1 2 1 3 4 5 1 6 7 1 8 9 10 11 12 13 1 14
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CONVERSION BURNER I 1 1
COOK STOVE I I 1 1
1 DIRECT VENT HEATER j I
DRYER I
FIREPLACE 1
FRYOLATOR 1
FURNACE •
I I 1
GENERATOR I 1
GRILLE I 1_
INFRARED HEATER I 1
LABORATORY COCK I I I
MAKEUP AIR UNIT I I
OVEN
POOL HEATER I
ROOM/SPACE HEATER I I It •
TEST1
1 TOP uNIT I r I I I 1 I I
UNIT HEATER l I I I I
UNVENfED ROOM HEATER I I I 1
WATER HEATER I I 1 1 1
1 11 11I 1 1 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 Ch.142 YES yQ NO ❑
if you have checked 1'FS•please indicate the type of coverage y checking the appropriate box below.
LIABILITY INSURANCE POLICY I� OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER 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 peril issued for this appl'icafion will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFI I I tit NAME: Mor— D;13 e✓ud 644 LICENSE#/rz)a' SIGNATURE
COMPANY NAME: Iy-a pt// ADDRESS: PDA fir)1. /4 Sl—
aw:
ZCITY: SA Oenn; r STATE MAL LP: 02460 . FAX
TEL: CELL S°g 3 9} 5 1/6 EMAIL:
MASTER[JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0 it PARTNERSHIP 0 a LLC 0 g
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II191'A.GEFOIRINSI'EC1'ORIUSE ONLX 'FINAL INSPECTION NO'I'IsS
OUGIT CAS .1'E • ► • .
Yes No
. THIS APPLICATION SERVES AS TI IE PERMIT 0 D
FEE: $ PERMIT# .
PLAN REVIEW NOTES
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