HomeMy WebLinkAboutG-14-1079 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
nv, DATE CP kI'i PERMIT 61`/4407907�
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JOESITE ADDRESS: 5 3 Naus-CA— Rd L" I- OWNERS NAME yrl d j-t 122°Ey I U
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G OWNER ADDRESS: I6 i/l)3 s 4 x y , N4'4446 TEL' SZt 372.74 r'FAY:.
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ / EDUCATIONAL 0 RESIDENTIAL,
PRINT
C.) CLEARLY NEW:0 RENOVATION:❑ REPLACEhENT:a PLANS SUBMITTED: YES 0 NO 0
'N APPLIANCES1 FLOOR-. Bsnt 1 2 1 3 4 1 5 6 7 1 8 9 10 1 11 1 12 13 14
BOILER I I I I
BOOSTER I I I I
CONVERSION BURNER I I I I 1
COOK STOVE I I I 1
DIRECT VENT HEATER I I I I _
DRYER I I
FIREPLACE I I J I _
FRYOLATOR I I I F _
FURNACE x I I ) I
GENERATOR I I I
GRILLE I I l -
INFRARED HEATER
LABORATORY COCK I I F I
MNC=UP AIR UNIT
OVA •
I_
POOL HEATER
ROOM/SPACE HEATER I I
I ROOF TOP UNIT
TEST I I I I I I ,_ I
UNIT HEATER, -
WASHED ROOM HEATERI I I I I
WATER HEATER I X 1 F I I I 11 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 $I NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY IN\ OTHER TYPE INDEMNITY 0 BOND 0
t OWNER'S INSURANCE WAVER:I am aware that the lironsee does not have the insurance coverage required by Chapter 142 of the
Massachuse . - - aw , , s at my signature on this permit application waives this requirement
jCIIIII CHECK ONE ONLY: OWNER.ET 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 I
Knowledge and that all plumbing work and installations performed under the pemrnd issued for this application will n co/mpliant with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws j h %,'_
PLUMBERIGASFII 1 CR NAME: PO der+ GI,/Se ^ LICENSE# a 433jn SIGNATURE
COMPANYNAME 60b PhUmb7ni ; f)& ij ADDRESS: 5b Lake_ 2d
CIN: C"' ' Year/nod `/ STATE yin ZIP:D ,'26,7-3--,;,F F: C-e1
TEL 7_!t! — 353 -11-0,CELL EMAIL t r ---C-_= 90 It
MASTER 0 JOURNEYMAN is INSTALLER 0 CORPORATION 0 it P'. t `ia Ig❑6 U�, 41 Uss❑
OUGII G S r SPE . _
ON ►01t: ' :MIS PAGE FOR INSI'EC7'OItUSE ONLY ;PIN AL INSPECTION NOTES
�ythit yam c1 Yes No 47 7/i/�V �1/`O 1P,C, 9
( THIS APPLICATION SERVES ASTIIE PERMIT ❑ ❑
alt 9a Y R EIf 67/5 vc. 1,4 if ?her
fire
oma/ F `Ftt'2 FEE: $ PERMIT II
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