HomeMy WebLinkAboutG-14-1042 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
e`" t CITY: �� / MP. DATE �✓l`� L n ' PERMIT# �� , n�����
�� JOBSITEADDRESS: Z4144o-s-hafaz OWI4ER'SNAME GL per4 11241
G OWNER ADDRESS:Sc /�yW antic /'M k:I RT - F I ,' DD FAX
TYPE OR OCCUPANCY TYPE: [ COMMERCIAL 0 EDUCATIONAL ❑ RESID 1 IAL L7
PRINTJUN 11 2011 I,
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: 12_ PL�NJa SBMriTEO: YES 0
NO[!r'
APPLIANCES? FLOOR-+ I Bsmt 1 I 2 3 4 I 5 r"7L _7..�'tt B g„I, 10 11 12 13 14
BOILER I i I I IJ I
BOOSTER I I I
CONVERSION BURNER I I I I I
COOK STOVE I I
DIRECT VENT HEATER
DRYER I
FIREPLACE I
FRYOLATOR
FURNACE I
GENERATOR - I
GRILLE I
INFRARED HEATER I I 1
LABORATORY COCK I I I I
MAKEUP AIR UNIT I I
OVEN I
POOL HEATER ! • I I I
ROOM/SPACE HEATER I I
I ROOF TOP UNIT
TEST
UNIT HEAT EH I I
UNVENTED ROOM HEATER I I I I
WATER HEATER I I
I I
I I I I
INSURANCE COVERAGE a �^
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Cit 142 YES [KO 0
If you have checked YES,please indicate the type of coverage by cherking the appropriate box below.
LIABILITY INSURANCE POUCY ter 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 applicadon waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of tie details and information I have subrr tted(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 compliance WM all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws
PLUMBERIGASFII rhKNAME:4- C lta-me UCENSE# SIG TORE ^�
COMPANY RklvIrG"t f-"c1 Ht—I1/1- C o'
ADDRESS30 G Cl. s4
Ce
CITY:D&owns Pw �- STATE M QQ- ZIP: 02631 FAX:
TEL 77$e-212-277s—cam r---- NAL_/9fle eCvnrcti t,NcScr--
MASTER[g JOURNEYIMMAN?1 INSTALLER 0 CORPORATION❑a PARTNERSHIP❑_ us❑g
OUGE(G S r SPL • O l . ; A'11.L9I'PAGE I+OIl11Y51'TCI'UIIUSI ONLY FINAL INS 1'gcl ION NOTES
Yes No
THIS APPLICATION SERVES AS TI IE PERMIT 0 U
PEE: $ PERMIT/l
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