HomeMy WebLinkAboutG-14-727 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS Fn IING WORK.
' CIT': 5, r 417 h [ MA. DATE 1/1y / 01-10/11 /� PERMIT# b///`7027
J06SIIEADDPESS: 3&—ND ^/ ot At- OWNER'S NAME /Jrhni3 kraal is
GOWNER ADDRESS: TEL: FAX
TYPE OR OCCUPANCYTYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 1V
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:ED: YES 0 NO❑
APPLIANCES? FLOOR—. I Batt 1 1 2 1 3 1 4 1 5 1 B 17 I 8 19 110 111 112 I 13 I 14
BOILER 1 I I 1 1 1 1 1 1 1 1 1
BOOSTER I I I I I I 1 I I I I
CONVERSION BURNER I I I I 1 1 I I I I
COOK STOVE I I I I
DIRECT VENT HEATER I I I I I I
DRYER I I I I I I
FIREPLACE I I I 1 I
FRYOLATOR 1 I I I
FURNACE I I I I I I I
GENERATOR
GRILLE I I I I IIII0 I
INFRARED HEATER I I 1 I 1 I I
LABORATORY COCK I I I 1 I 1 I
MAKEUP AIR UNIT
OVEN I I I ��� I _O
POOL HEATER I I I • I
ROOM/SPACE HEATER, I 1 I I
ROOF TOP UNIT I I I
TEST 1 1
UNIT HEATER I I =inn
U 'alias -••r 1, a- I I
WATER HEAL LK I I
I I I I
MIIIISMIIIIMMINIIIMS
INSURANCE COVERAGE
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES V NO ❑
If you have checked YES,please indicate the type of coverag y checking the appropriate box below.
UABIUTf 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 tue 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 compliance with all Pertinent
proton of the Massachusetts State Plumbing Coe and Chapter'142 of the General Laws.
PLUMBERIGASHtutHNAME &L wi/So,✓ UCENSE# ov1331 SIGNATURE
COMPANYNAME ad 's 914w.b,A1 "ril[a7Aj ADDRESS: S6 44e RP
CITY: 'Ar' YaOlt a✓71\ STATE: MA ZIP: ael73 1 FAX
TEL CEI: 27'135-3 rot EMAIL•
MASTER❑ JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0 a aiE D LLC❑:
Lir4JAN29 ' _
2014 atfr
EPA ENT
By
OUGIIGA f .VILC • l • E.' OS Pi#G1:FOR INS'JLUO71UNE ONLY FINAL INS LTell ONNOTES
Yos No
THIS APPLICATION SERVES AS TI IE PERMIT ❑ 0
FEE: $ PERMITS _
FLAN REVIEW NOTES
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