HomeMy WebLinkAboutG-14-838 '` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS b I I INt WOKS.
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JOSSIEADDRESS: 2/1 424% { 2(400pOWNER'S NAME: e jf
to 447A/en
OWNER ADDRESS: TEL: FA
TYPE OR OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL 0 RESIDENTIAL 21/
PRINT
CLEARLY NEIN:[� J RENOVATION:u REPLACEMENT:❑ PLANS SUBIv1 IT ED: YES 0 NO.-
APPLIANCES? FLOOR-* Bsnt 11 2 3 I 4 I 5 6 7 1 8 9 10 11 12 13 14
I BOLES I I I
BOOSTER I I I
CONVERSION BURNER
COOK STOVE I I I
I DIRECT VENT HEATER I I
DRYER I
FIREPLACE I I
FRYOLATOR I I
FURNACE I . I
GENERATOR I I
GRILLE
INFRARED HEATER I I I _
LABORATORY COCK I I I I I
MAKEUP AIR UNIT I I I I
OVEN I
POOL HEATER I IIt • I
ROOM/SPACE HEATER, I I I I I I I
I ROOF TOP UNIT ( ( I I I I I
TEST I I I I I I I
UNIT HEATERI I I I I I I I
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UEN ED ROOM HEATER I I I I I
WATER HEATER I I I I I I l 1
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WSURANCE COVERAGE 1
I have a current liabiitrtv insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES-CJ NO 0
If you have checked YES,please indicate the type of covers a by checking the appropriate box below.
LIABILITY INSURANCE POLICY [ 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this applcation are true and accurate b the best of my
Knowledge and that all plumbing work and insallations perionned under the permit issued for this application will be'a/mob=with all Pertinent
provision of the Massachusetts State Plumbing Code a d Chapter 142 of the General Laws. i �/
. PLUMBER/GASH i I tKtdAME coq y�r
....72 ottL/S LICENSE g, ' ySIIGNATURE
COMPANY NAME614,11��(JGGJJ I/6 Ail ADDRESS: `0 aft,/ e
CITY x741 04 STATE,f. 5 LP:(%rk9 FAX:
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WASTERJOURNEYMAN I] LP INSTALLER CORPO,RATiON0a ': Iris Il1�1 �V E 0 !loge
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