HomeMy WebLinkAboutG-14-663 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
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1 Mk DATE 1- 7-/y PERMIT# C�'7 —66-5
JOBSTrE AD KESS: V S v r+ 4ht(-1 OWNER'S NAME O
GOWNER ADDRESS -d P_!'o' TEL' FAX
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yobt�oPr+ TIE:PE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 2
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES1 FLOOR Bsmt 1 1 2 3 1 4 5 6 7 1 8 1 9 10 1 11 12 13 14
BOILER 1 I
BOOSTER I I I
CONVERSION BURNER I I I I
COOK STOVE
DIRECT VENT HEATER
DRYER I
FIREPLACE I I
FRYOLATOR
FURNACE / •
GENERATOR I I
GRILLE
INFRARED HEATER I Il
LABORATORY COCK I I I
MA10 UP AIR UNIT I I
OVEN f I I I I
I POOL HEATER •
_
I ROOM/SPACE HEATER I 1 I I •
I ROOIRTOP UNIT I I I I 1
TEST' I / I
UNIT HEATER I I I I I
UNVENTED ROOM HEATER I I I CII I
WATER HEATER I / r I I E IG 9 rvI EAil DI
I
INSURANCE COVERAGE U / LV
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NAL ;h.142 YES ,] NO n
BUILDING D Y, TMENT
If you have checked YES,please indicate the type of coverage by checking the appropriate box below. BY: C!a 9I%
LU16ILITY INSURANCE POLICY a- OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WATER I am aware that the licensee does not have the insurance cove-age required by Chapter 142 of the .9-70r.d
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 submitred(or entered)regarding this application are the and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permli issued for this application will be in compliance with all Pertinent
provision of The Massachusetts State Plumbing Code and Chapter 142 of the General Laws. S7- _
PLUMBE /GASFII !titNAMRJ( 610usv j"f'r' LICENSE# 2'3 &a SIGNATURE
COMPANY NAME -,.6( 4-e ,t..o—ft. flu—.(,._7 ' ADDRESS: L/2 /t CtLq rbe,/ La---„a
'IAA STATE ZIP: 024 3) FAX:
Ta_r -' S->612 caL:77y-)-/a- 20/ I EMAIL
MASTER❑ JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑a PARTNERSHIP❑ LC❑
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