HomeMy WebLinkAboutG-14-835 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
OW: 1/naw1a? -TI4p flag— MA' DATE 3/).//14-) PERMIT
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JOBSITEADDRESS: / ) �J417•irJ2, S/J .nnJU
� p� fes, OWNER'S NAME l.J'DYL6I�
OWNER ADDRESS: TEL' FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL EJ EDUCATIONAL ❑ ,RESIDENTIAL i
PRINT ^/
CLEARLY NEW:ltd RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
APPLIANCES-1 FLOOR-. Bsmt 1 2 3 1 4 1 5 6 7 1 8 9 10 11 1 12 1 13 1 14
BOILER
BOOSTER 1 1
CONVERSION BURNER I I I
COOK STOVE I I I
DIRECT VENT HEATER I I
DRYER I I I
FIREPLACE
FRYOLATOR I I I I I
FURNACE I I I I
GENERATOR j I I
GRILLE
INFRARED HEATER I I L I
LABORATORY COCK
MAKEUP AIR UNIT I I I I 1 I I
OVEN
I I
POOL HEATER I
I IIF
ROOM I SPACE HEATER
I ROOF TOP UNIT I I
TEST
UNIT HEATER I I I I I I
UNVENTED ROOM HEATER I I I I I I
WATER RESTER I f I I R 1E GI E D
I I I I I
I I II I
INSURANCE COVERAGE FLAK 11
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MQ.Ch.142 YES TA 0
BU I LDINGCAEEF
If you have checked YES,please indicate the type of coverage by checking the appropriate box below. By.
LIABILRer /
Y INSURANCE POLICY L�� OTHER TYPE INDEMNITY 0 BOND 0 Pc r
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 submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed underthe permit issued for this application will be in compliance with all Perlinent
provision of The Massachusetts State Plumbing Code and Chapter 142 of the General Laws. > A
PLUMBERIGASFItKNAME: 111,3 (jn' /We LICENSE# 2,764' TURF
COMPANY NAME Ni PZ cj -I u t5 ADDRESS: / 4/071//0(71
CITY /AA %fl f??b)M STATE 44,4 • ZIP: 4247 3 FAX:
TEL ,Sag-?'16-7,3Lig caLL: EMAIL:
MASTER 0 JOURNEYMAN EK LP INSTALLER❑ CORPORATION 0# PARTNERSHIP 0 LLC❑it
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OUCH GAS TPL. p T 0 Op. II' �I11SPAGE FOR JNsl'EcroltUSE ONLY ;FINAL INS PCCI'IONNOTES
&El MI. C!, G/.%i 1— cl, oyrt/ Yes No
THIS APPLICATION SERVES ASTIIE PERMIT ❑ ❑
FEE: $ PERMIT G
)'LAAN RTYffi\Y NOTES
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