HomeMy WebLinkAboutG-14-909 ' I MASSACHUSETTS UNIFORM APPLICATION FOR A PERM 11 G PERFORM GAS FITTING WORK
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GOWNER ADDRESS: TEL' FAX /
TYPE OR OCCUPANCYTYPE COMMERCIAL❑ i9OUCATIONAL ❑ RESIDENTIAL 6
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:61 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR Ssmt 11 12 3 4 I 5 I 6 7 1 8 9 10 11 12 1 13 I 14 •
BOLES I I
BOOSTER
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CONVERSION BURNER I I I I I I
COOK STOVE I f I I
DIRECT VENT HEATER I I I I
DRYER I _I I
FIREPLACE
FRYOLATOR I I
FURNACE I ' I '
GENERATOR
GRILLE
INFRARED HEATER I I
LABORATORY COCK , I I I I
MAIIEUP AIR UNIT I I I
OVEN
POOL HEATER •
ROOM/SPACE HEATER I I
I ROOFTOPUNIT I I I I I
TEST I I I I I I
UNIT HEATER I I I
UNVENTED ROOM HEATER I I I I I I 1
• WATER HEATER I I I I ' I
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INSURANCE COVERAGE
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO ❑
If you have checked YES,please indicate the type of cove a by checking the appropriate box below.
LIABILTI'INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER: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 subrritded(or entered)regarding this appicatfon are true and accurate to the best of my I
Knowledge and that all plumbing work and installations performed under the permft issued for this application will be in compliance with a •erlinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBFR/GASFII ItJNAME: J,,:. MLS I LICENSE# IS903 SitIrr RE
COMPANY RARE: Cr M p ADDRESS: )01 RA\t.<�
CIN: S,• 1kritc`, STATE/_ ZIP:Qd (2 FAX
TEL: 5-Oc- Sri •-SaS CELL Sao-317 -ss)s EMAIL:
MASTER d JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0 it 1, E e; 5-N H .� US a
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BUILDING DEPARTMENT
OUGf[G I SPI: "_ O ►O . MIS PAGE FOR.INSIJ.Cl'OIl USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS TIIE PERMIT ❑ U
FEE: $ PERMIT if
FLAN REVIEW NOTES -