HomeMy WebLinkAboutG-14-703 ....ns.,_ MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
t ell /..9/41-705G,; r0 V 7�L F MA DATE //� /� PERMIT r
JOSSITE ADDRESS- �. d . i a / . ! or •WNER'S NAME: 134REL1 ST vC `a-C to
GOWNER ADDRESS: 69 Om cfrtrA r1/ASHu� FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL CZ
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CLE_4BLY NEW:0 RENOVATION:M REPLACEMENT] PLANSSUBIviITED: YES 0 NO
APPLIANCES? FLOOR-• Ssr,G 1 1 2 1 3 1 4 1 5 6 7 1 8 9 10 11 12 13 14
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ROOM/SPACE HEATERI I I I I 1
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UNVENTr ED ROOM HEATER I I I I I I I 1 ,
WATER HEATER 1 / I I 1 1
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES A NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriats box below.
LIABILITY INSURANCE POLICY till . 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 rrry signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT ❑
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 permit issued for this application v s'6 be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER)GAS}-ti1tlNAME: /jfl rb/L t-Rrico LICENSE# IC6c SIGNATURE
COMPANY NAME: Lbau—OA- toffCo ADDRESS: 197oc-b (o-on/tf-!ft)
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CITY: /yrA Afolas STATE HA • ZIP: O,--C40, FAX
TEL snSr 776c739y CELL: Saf774W397 EMAIL'
MASTERgi JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0;t PARTNEERSHtP 0' LI.G❑g .