G-14-783 a/i i ;
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
7.40 t �J II h
rta, CITY: I p�'vH9.0MA. DATE 19 l t f5 I t t PERMIT# /WV" 71)
JOBSITE ADDRESS: 5 9 1414e- 'a 'U7es4- OWNER'S NAME Calls" -R1A C 1.4.Ste.
GOWNER ADDRESS: IG2 ad, phi"- TEL 725-- 0J-SO FAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALEI
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:L?¢ PLANS SUBMITTED: YES 0 NO 0
APPLIANCES? FLOOR ssmt 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
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES)] NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY/e 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 ❑ 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 hue and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will e i co lance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: Al aIJ6 n 0 LICENSE# 90z3' / SIGNATURE
/ c
COMPANY NAME: (Cr/!1 pori lt✓Ghkar Ch ADDRESS: if G/vI c PUG
CITY• C- ya r r~v._b\ STATE: 1^4-A ZIP: 0 a-CC.tf FAX: SOS.I5
TEL: 3Cl q— 7,�( CELL: fa- VI b- EMAIL: F . • " Siospoirstrife •s O /
MASTER JOURNEYMAN 0 LP INSTALLER 0 CORPORATION'#?o 16 C PARTNERSHIP II# -- -t[C d# 1 1
FEB 18 2014v. ini
By —
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