HomeMy WebLinkAboutG-14- ,•;_/ �. MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS,FITRNG WORK_\ I
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CITY: /R(to tr-n1D h MA DATE f 111'1001 P&JJR I 6/9—
JOBSITEADDRESS: 3 S9 V /1,V O OWNER'S NAME P4° f -7-17-0%-f
GOWNER ADDRESS: !! 3 Sf vftnt` TEL' FAX
POTOCCUPANCY TYPE COMMEeJ FAX
PRThi0D
CLEARLY NEW:0 RENOVATION:0 REPLACEMMENT:j -�— . PLANS SUBMI I S: YES 0 N00
APPLIANCES 2 FLOOR-+ Bsmt 1 1 2 3 1 4 5 6 7 1 8 1 9 1 10 1 11 12 13 14
I BOILER I I 1 I I
BOOS f Ct 1 I I I
CONVERSION BURNER I I I I
COOK STOVE I I I
DIRECT VENT HEATER I I
' DRYER I I
FIREPLACE I I
FRYOLATOR I I I I
FURNACE I • I
GENERATOR
I GRILLE j I
INFRARED HEATER I I I
I LABORATORY COCK I I I
I
MAKEUP?JR UNIT I I I
OVEN I I
I POOL HEATER I I
ROOM/SPACE HEATER I I I I
1 ROOF TOP UNIT I I I 1
1 TEST I I 1
UNIT HEATER I I
I UNITED ROOM HEATER I I 1
I WATERHEAI 1t J I I I ' I ,
IIM0
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Cit 142 YES NO ❑
If you have cher ed YES please thdicatethe type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POUCY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER 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 subrrilded(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 will be in oompilan = • Anent
provision of The Massarhus tis State Plumbing Code and Chapter 142 of the General laws (\ �
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PLUMBE21GASl-IIItkNAME: r'p4nJc'c c 7,,e re LICENSE#5` SIG
COMPANY NAME: Ftp,n ti 7 cM ft l•ff- ADDRESS: P.o 6 o•t G 7�
CITY: u 1 K?it'v vi S7f STATE/YI a- ZIP:02 to 22 FAX:
TEL' lel,'5 775"-1395 6 ' 73 7 9 o Z EMAIL: _
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MASTER-JOURNEYMAN 0 LP INSTALLER 0 CORPORATIONJ 332— P r .❑s
11102 b i RAJ
Ci - A1303 'd
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OUGIL GA ►L I
r ."_ 1 IP ► ► • r ' }'ILLS I'AGJS-POR.macron WE ONLY FINAL MISI'ECI'ION NOTES
Yos No _.
THIS APPLICATION SERVES AS TIIE PERMIT 0 0
FEE: $___________. PERMIT A —
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