HomeMy WebLinkAboutG-15-064 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS I0 1 l..4.44 i:5 Ro.LJ OWNER'S NAME '-C-LSC gtcon;Z
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G OWNER ADDRESS - (TEII (FAX
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OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL❑ RESIDENTIAL El
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CLEARLY NEW:❑ RENOVATION:IJ REPLACEMENT:g PLANS SUBMITTED: YES Q N06
APPLIANCES 7 FLOORS-• ESM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER MS NM:5 IIIM MMM_'.M Mt t.5 MMR MMM MMM 01.111.5 MMM
BOOSTER 5 5 MIS—MMM MO MMIq:Mt_a t ISM MB
CONVERSION BURNER N;5 a s t:t Mt t,a SM.t MIK Mme;Mt
COOK STOVE MtMMRMil lNON i■aMtaMMMaatII:aaa
DIRECT VENT HEATER MIN:a aSi to s 1 Mitt a a a a';a a
DRYER a:' .a 5 5 S MMM Mt Mme'.M Mt.Mt Mt.Mt
FIREPLACE MMR a MMM MMR a a a a MMIC a a a a a a
- FRYOLATOR IS Mt Mt MMM a:a Mt.MMM MMM 111111111 MINI SI Mk MM:a
FURNACE 5 5 Mt:MMK NM MIS a s[a MMB INS a PM M a
GENERATOR 1 s a 1 a:as Mt MMM MK NS Mt M1SMt Mt
GRILLE 11111111,11111111 t MMM 11.11111111111 n PPM MIN 11111111,111.111 a'a::a a
INFRARED HEATER 0.1111 Mt Mt Mt ars MMR MMM a ass s a a a
LABORATORY COCKS MMR MMM Mt MMM MMR s a a a a a a a a
MAKEUP AIR UNIT M1 a MMM MMI a Mt MMR Mt Mt as n sa a
OVEN all MMM Mt a MtIa a Mt MIM a MS MMM is MMR a
POOL HEATER aa Mt;MMM a t a a,N 11•111SIMIIII.111.11111111
ROOM I SPACE HEATER MMS as MMI IS a a MMM.a a a,a Mt;Mt;Mt
ROOTEST TOP UNIT ttsMS MS illl.saaMMRaNMI NMI anaa
UNIT HEATER Mt a MMR s Mt M� MI MMMM Mt M I MM 5 5 a t
MMRiMt Mt
UNVENTED ROOM HEATER Mat Mt MMR MMI',s MMM:MMM MMM MMR!MIK M1MIK,„a a
WATER HEA • MMM[MtaaMtaaaaMtaaaaa
OTHER ;Mt Se Mt Mt MRK;MMR a aia MMR'a a a a i
M=IMMMAMOmint MM[!MMM,a.a'a'MEMSMMI,M MK Mt
Mt a Mt Mt MMR;a a s MRM MMM MMR MMM a Mt:MEI
a a a .NMM.MI M Mt t lINS.t.MS Mt,MMt.MMM Mt
INSURANCE COVERAGE -_-_. 1 ' I
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 14 r.YES'IN 0 NO' ,.—_,
1W YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY DECKING THE APPROPRIATE BOX BELOW Ian
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LIABILITY INSURANCEPOUCY`4 OTHER TYPE INDEMNITY ❑ BONDiQ 1
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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
I 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 pkmbing work and Instaeations performed under the permit Issued for this application writ be In lancewith II t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ham_
PLUMBER-GASFITTER NAME RON / ii HACa( I LICENSE#1631, ( I NATURE
MP tla MGFQ JP JGFQ LPGIEi CORPORATION 0# PARTNERSHIP 0# • LW 0#
COMPANY NAME: 6Wf,Pl.fl,KB!lJ iffili/Aj1 (ADDRESS 6„2IFGI) RO.<T/u) 4W. I
CITY MA'/OS ' STATE Ern ZIP (kms 3' TEL .COR- 38.s-?7s's” I
FAX j CELLicard6adtEMAIL roythAi30.49.@ &nategi+ Tot I
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