HomeMy WebLinkAboutG-14-699 1 I - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOESCIE ADDRESS: I 0 U-1.5-i S r OWNER'S NAME $'cJ Z 1 L X44..-
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\ k 1 G OWNER.ADDRESS: lO 3 (fin,i , S f /Grn c.I(TEEL• 54 !3 9 z L Loci FAX
? 1SRn OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENT UAL '
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G CLEARLY NEW:0' RENOVATION:0 PEPLACEAENT:0 PLANS SUBMITTED: YES 0 N0 Ery
1 APPLIANCES? FLOOR-+ Bsrnt 1 1 1 2 1 3 1 4 5 1 S I 7 I 8 1 9 I 10 11 12 13 14
1 BOILER I I I II I I I
aOOSItR I 1 1 I I I I I
/0 2 1 CONVERSION BURNER
lyi COOK STOVE I I I I i I I i
1 1 DIRECTVEN HEATER I
DRYER I 1.
FIREPLACE I I 1 I I 1 I
FRYOLATOR I I I I I I
FURNACE
I GENERATOR i 1 I A
1 GRILLE I I I I
INFRARED HEATER
1 LABORATORY COCK I I I I I
1 MAKEUP AIR UNIT I I I
1 OVEN I I I
I. 1 POOL HEATER I I I I
ROOM/SPACE HEATER
I ROOF TOP UNIT I I I I I
I TEST I I I I I
I UNIT HEATD? I I I I
I UNVENTED ROOM HEATER I I I I I I
I WATER HEATER 1 1 I I I I 1
1 I I I I I I I
I - I I I ! I
I I I I I
I INSURANCE COVERAGE �,/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO E
If you have checked Y_E_S,please indicate the type of coverage by checking the appropriate box below.
. LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WARIER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Ins,and that my signature on this permit application waives this requirement,
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i / a _' CHECK ONE ONLY: OWNER 2 AGENT 0
' NAI ' 0 a , r or AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this appficauon are true and accurate to the best of my
Knowledge and that all plumbing work and instillations performed under the permit issued for this application will be in compliance with all Pertinent
provision of the Massachusetrs State Plumbing Code and Chapter 142 of the General Laws r i
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PLUMB R/GASF'I i ER NAME: Brc�nY 7'ln e It' LICENSE# 36 6 ' SIGNATURE
COMPANY NAME I v,n.., 1-1:- P1 H..,4 say ADDRESS: l!7 3 Von/On St"
CITY: fin---.;.„ f/, "ori STATE /414 ZIP: O2 & 75- FAX:
TEL: Sol - 9 ZL-Lfodl CELL' cT.r, Y. EMAIL'
MASTER 0 JOURNEYMAN IPYLP INSTATIER 0 CORPORATION 0 z . - PART ltl I v E riihO g-
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JAN W6 t1 1 GRID
BUILDING DEPARTMENT 1
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