HomeMy WebLinkAboutBLDG-19-005139 7-i: asMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
n__ CITY: 1 v Gr wkov4-L —We MA. DATE: 3I , I 1CI PERMIT#nh/V7? `�
JOBSITE ADDRESS: 2 a I C r.ve r aOWNER'S NAME: S4'e vc k✓a;•i-e-
G OWNER ADDRESS: TEL: FAX:
TYPE
TOR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENTIALPRIN
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CLEARLY NEW:0 RENOVATION:I' REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES1 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
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GENERATOR - r
. GRILLE
ki} INFRARED HEATER
W LABORATORY COCK
MAKEUP AIR UNIT
P4,4 OOL
HEATERr C g 1 E. 1;
' ROOM/SPACE HEATER
-NI ROOF TOP UNIT
t TEST '( MAR �.j 1 2C.44-
UNIT HEATER y a
t j UNVENTED ROOM HEATER Elt D N G o_PA P T to '
WATER HEATER I ,
INSURANCE COVERAGE
I have a current liablity insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES jgcNO 0
if you have checked YU,please indicate The type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY, OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee Aggincain 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 appication are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application wii bn In piance with all Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. ''yt/�
PLUMBER/GASFITT(ERNAME: i/mark•00rpvan`�G.^. LICENSE# /t�Z` C) t 1p�SI u1
COMPANY NAME: t'�00 T 0 vv►`I st r^r ADDRESS: 2 L vber Ln c>< 0 f,
CITY:\A)t a0 y l s Vo Y. STATE: MA- zip:0 IS-9 3 FAX:
TEL:5O/4-7C9'9J73 cat. So EMAIL IY.k k Y P k-s Cra PAS tt t col\A
MASTER rg JOURNEYMAN❑ LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
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