HomeMy WebLinkAboutG-14-764 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .
" a CITY: YL/!90 c'/-4 MA DATE I/�/S' PERMRr bkJ�4y
JOBSITEADDRESS•, 77G•Gf .Qoi \ _ OWNERS NAIVE:Cyn 4%' QnlleL—
G OWNER ADDRESS* TEL'S r9S'-n/O FAX
TYPE OR -OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENTS PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR I- Bsnt 1 I 2 3 1 4 5 6 1 7 8 9 110 11 _12 13 I 14
L
BOI
BOOSTER I -
CONVERSION BURNER - I
COOK STOVE _
DIRECT VENT HEATER I _ • a
FIREPLACE 1 I I - I I
FRYOLATOR I I _
FURNACE - -
GENERATOR - _
GRILLE • 1
INFRARED HEATER _
LABORATORY COCK _ I ;
MAKEUP AIR UNIT
OVEN
POOL HEATER -
ROOM/SPACEHEATER I •
1 ROOF TOP UNIT - -
TEST
UNIT HEATER _
UNVENTED ROOM HEATER 1 _
WATER HEATER /
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets The requirements is of MGL Ch.142 YES 0 NO 0
If you have checked Y_,,ES, please indicate the type of coverage by checking the appropriate box below.
UABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WANER 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 cerhiy that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that al ptnmbing work and installations performed under the perm issued for dins application wi l be' wit al Pertinent
provision of the Massachusetts State Plumbbhg Code and Chapter 142 of the General Laws
PLUMBER/GASFIrtut NAME: i42v/n Iirtanieie' — LICENSES IIL+oZr , SIGNATURE
1 M
COMPANY NAME k' CJQdrIP_ Plum+ UeM t/kADDRESS: 1I Corinrai- P�h
env: Ili.Yang.,n, A1, STATE .[ 11_ LP: n2673 - Ho-�5ocli�+o-5785
TELT DO-7n—4656 call5ok'364-3794
MASTER d JOURNEYMAN❑ LP INSTALLER 0 CORPORATION 91/4 a&6ga P 4 & Lii?Jiico r
LFEB 11 231a I �
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