HomeMy WebLinkAboutbldg-19-003694 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK fi%'?9
u= CITY:We•& yik.1446x7-71 MA. DATE /2A/ 47 PERMIT# LID6 --CO,tirg
`1 JOBSITE ADDRESS f�M/sI�f OWNER'S NAME: -50 �d L�v4
G OWNER ADDRESS:2- d E tT,L&f TEL: FAX:
TYPE OR OCCUPANCY PE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
APPLIANCES FLOOR-• Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER _ _
COOK STOVE
DIRECT VENT HEATER ,
-
DRYER
FIREPLACE
-FRYOLATOR
FURNACE
GENERATOR
GRILLE
V) INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT ;
IZZ'
,T POOL HEATER
ROOM/SPACE HEATER
NI ROOF TOP UNIT J f i.,
TEST
.Z UNIT HEATER —
tyl UNVENTED ROOM HEATER -- ___ _ ::. ,
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES �O ❑
If you have checked Yll,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 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 ❑
SIGNATURE OF OWNER ORAGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application a : ..: .1 ,a•.,i As to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this applied. wil be I /711 all
provision of the Massachusetts State Plumblpg Code and Chapter 142 of the General Laws./
PLUMBER/GASFITTER NAME: AV/6 � �5 LICENSE#437�/7`[A._ SIGNATURE
COMPANY NAME: X0 SS P u'hL ADDRESS:3 C�`rcl44?;6� , t'
CITY: W6. 7144s10VA STATE: eiS' ZIP: ov673 FAX:
TEL: CELL:_9Y'.Y/7 Y Y EMAIL' ///l 4/Qlff/" fs4Ll!✓e. co Ai
MASTER JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# LLC 0
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