HomeMy WebLinkAboutG-14-952 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Gif: rAitielaJY-e MA. DATE $l6/cr PERMIT# //I41�Y7
y/ c Jossrr ADDRESS. SS 721SMA�(///`} OWNER'S NAME
\� (S - OWNER ADDRESS: TE: FAX
TE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDEMAL
`
61\/ CLEARLY NEW:0 RENOVATION:0 REPIACEMair:❑ tfE - rtsr l/4Cit Fo e q'‘IrES NO❑
APPLIANCES-1 FLOOR Bsmt 1 1 2 3 1 4 5 6 7 1 8 1 9 10 1 11 1 12 1 13 1 14
BOILER / 1 I I 1 1
BOOSTER
CONVERSION BURNER 1 I I I I I
COOK STOVE
DIRECT VENT HEATER I I I I
DRYER I I I
FIREPLACE I 1
FRYOLATOR I I I I
FURNACE I I I I
GENERATOR I I
GRILLE
INFRARED HEATER I I I I
LABORATORY COCK I I I I
MAiLFUP AIR UNIT I I I
OVEN
POOL HEATER • I I I I I -
ROOM/SPACE HEATER I I I I
I ROOF TOP UNITTEST
r I I I I I I 1
UNIT HEATER
• UNVEMED ROOM HEATER I I
WATER HEATS I
• - Od.1- I��IJIU�l`I++
INSURANCE COVERAGE '11Uc 90 AII
AIM
have a current liability insurance policy or its substantial equivalent which meets the requirements of\IG-Ch.142 YES ❑ NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below. Q 3 A a C) 2 d:!
LIABIUTYINSURANCE POLICY OTHER TYPEINDEMNITY 0 BOND 0 ‘pc�F'
OWNER'S INSURANCE WAIVER n I am aware that the license does not have the insurance coverage required by Chapter 142 of the 'T.
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWER OR AGENT
hereby certify'y'that all of the details and information I have submit-dad(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 pemul issued for this applicafion will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 74 �; 'A
PLUMBER/GASHi tttNAME: EVA-f-TVI LCV to LICENSE# `75-65' SIb , RE
COMPANY NAME. //M c -re L D.ficr, ADDRESS: /91 o c COCOAJ ' e0
ClIY: Hfli1/4 c STATE: HA ZIP: OAS O ( FAX
TEL' CELL:5r5'-776554379 EMAIL:
MASTER(R] JOURNEYMAN 0 LP INSTALLER❑ CORPORATION 0 a PARTNERSHIP 0 a LC 0 R
oUGI GAS INSPE ".1•-�► • BILsMOEFOILINSI'TCTOItUSE ONLY I�INALMIS REMONNOTES
dFe /-43,174 ,7/fa/�� Yes No
&
�� �� Tills APPLICATION SERVES ASTIIEPERMIT ❑ 0
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FEE: $ PERMIT#
)'LAN REVIEW Notos —