HomeMy WebLinkAboutG-15-1395 =� I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS Fn 1iG WORK
r. CITY: _j4I tAit& MX DATE r126(IV PERMR /.�/zi/e-�1�,77 r
I�- JoBarTtADDP.ESS• 25 LJ344$,Od�. OWNER'S NAME: `tCSZ
GOWNER ADDRESS: TEL FAX
6GGGG���"""",lp TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDB'I IAL
\ 40114 PRINT
Nett rT.V 42LY NEW:® RENOVATION:❑ REpLACEYIENT:❑ PLANS SUBIv1I I I tut. YES❑ NO❑
APPLIANCES? FLOOR Bsrt 1 2 1 3 4 5 6 7 1 8 9 10 11 12 13 14
BOILER I I
BOOSTER I I
1 CONVERSION BURNER I I 1
COOK STOVE I I I
DIRECT VENT HEATER
DRYER 1
FIREPLACE I I
FRYOLATOR I
FURNACE I
GENERATOR
GRII1F
INFRARED HEATER I I
LABORATORY COCK
MAKEUP AIR UNIT I I
OVEN
POOL HEATER •
ROOM/SPACE HEATER I I I
I RTE�TOP UNIT
.UNIT ttEat_�� V 1) I I I
'UN\eCt-ROOM H--J I II
WATER h'EATE2
111 ,5", 262014 I I i i I I I
I� :lin n-11 I I II I I I I • •II I 1 I
INSURANCE COVERAGE
Y haat93+d I. ,1 msmance poky or its substantial equivalentwhich meets the requirements of MGL CIt 142 YES Q NO 0
If you have checked YES please indicate the type of coverage by checking the appropriate box below-
LIABNTY INSURANCE POUCY ® OTHER TYPE INDEMNLTY 0 BOND 0
OWNER'S INSURANCE WANER I am aware that 11-a licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signabae on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT l
hereby certify that.all of the details and information l have submited(or eniered)regardIng this appkafion are true and acauaieto tate best of my
Knowledge and that all plumbing work and insulations performed underthe pernul issued for this appGcafion will be in compliance wit all Pertinent
proton of the Massachusets Stale Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASH i i ti4NAME: keufrk r3IQu1-1-c-s-44 LICENSE* SO904 SIGNATURE
COMPANY NAME_ lt10 010 i, ADDRESS: to S""'•" St' Lik04-I'2
CITY• ikv1Nl5(AY* STATE ZIP: aLL3' • FAX
T7`(-Zt2-2L6$ CELL' EMU:
MASTER 0 JOURNEYMAN Lel LP INSTALLER❑ CORPORATION❑a PARTNERSHIP❑= I!C❑ :
Lie if
OUG • r is PE " is. 1, 9 r ' DUN PAGE EOM INSPECTOR UNE ONLY J'INALLNNPPCI70NNOTISN
R!¢if 634 ad82f l Yos No
TI IIS APPLICATION SERVES AS TI IE PERMIT 0 0
_ FEE: $ PERMIT P
J'LAN REVIEW NOUN