HomeMy WebLinkAboutG-15-062 MASSACHUSETTS UNIFORM APPLICATION FOR APERNMITTO 'ERF•RM GAS FITTING WORK
GN: MA. DATE
0 PERMIT# egra-06'42
'( JOBSITE DRESS: J L S 1' Ar • =-is a � re k.G OWNER ADDRESS: r 7 4 TEL' FAX
TYPE OR�' OCCUPANCY TYP ' COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
PRIIv
CLEARLY NEW: ,ENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES1 FLOOR Bunt 1 1 2 1 3 1 4 1 5 B 7 1 8 9 10 11 12 13 14
BOILER I 1 I 1 1 1
BOOSTER I I I I I I
CONVERSION BURNER I I I I
COOK STOVE I I I
DIRECT VENT HEATER
DRYER I I
FIREPLACE I I
FRYOLATOR I I
FURNACE I I
GENERATOR I
GRILLE I
INFRARED HEATER I
LABORATORY COCK I I
MAITUP AIR UNIT
OVEN I
POOL HEATER I •
ROOM/SPACE HEATER I
ROOFTOP UNITTESI F I I I I
UNIT HEATER I I I I I I
UNVENTED ROOM HEATER
WATER HEATER I l/I I I n I I I I
I l I I I I I ) ^
INSURANCE COVERAGE /
I have a current liability insurance policy or its subs'antial equivalentwhich meets the requirements of MGL Ch 142 0 0
If you have checked LES_,please Indicatethe type of coverage b eating the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
OWNER'S WSURANCE 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 carniy that all of tire details and information I have submitted(or entered)regarding this application are true and a • -te to the best of my
Knowge and that aplumbing work and instillations performed under the pearl for this application will be
lsdd in ; .nce with all Pertinent
provision of the Massachusettluting Code and Chapter 142 of the General Laws.
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v Dry Q4-- NATIJt te-- it ADDRESS: 24i if a� •�
CITY• 1/24160J07174 STAT 7IPt la0 73 FAX
TEL', (J .7FJ6 iCEll: EMAIL: r4 r_ r 1= E V F ID
MASTER ICS. -dCTRNEYMANNSTPJJ ER 0 CORPORATION❑# P'1'ESS'HLP❑# �. l� s
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OUGE G S .1'LC'. ll Ilk ►O S. 'IBS PAGE FOR INSLECl'OIIUSE ONLY 'FINAL INS l'ECE1 0 N NOTES
C¢ oz Gr2// S y Yes No /V/71-74967 -leaC6t�v'vs'
> TRIS FlPPLICATICN SL"RVES I STFIE PERMIT 0 0 r 6071-1 /AUn_ r L
FEE: $ PERMIT II 7/3/Jif Ail-e-Ail-e-C Ort/7e11
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