HomeMy WebLinkAboutBLDG-20-001631 t. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
s CITY: /r/,r,,•741vl 4,0a,"✓r MA. DATE / PERMIT# D)9'o26--eV/6 /
JOBSITE ADDRESS Pen z, 6 , /e OWNER'S NAME: VA2i/, d M/C,hv �, ,jk.-t'
G OWNER ADDRESS: �fAo//r �.��,,,, ,,,,-/n/O TEL:7 7V 99//7I 31' FAX:
TYPE OR OCCUPANCY TYPE:/ COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PFUNT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMEN1,ED PLANS SUBMITTED: YES❑ NOD
APPLIANCESZ 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
to INFRARED HEATER --~---- D
1.43 - 1 F L....21_,RF,--Y- - - - --0q40)
I LABORATORY COCK
MAKEUP AIR UNIT '
OVEN il
POOL HEATER ! w,-- 24 ?_VI • ,
ROOM/SPACE HEATER _ •
I ROOF TOP UNIT ? .# J i �. a r, , n W` T
s TEST - .._-
UNIT HEATER ' _ _, `'-
i. UNVENTED ROOM HEATER
WATER HEATER
AO -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NdjZID
If you have checked Yam,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 m signature on this permit application waives this requirement
CHECK ONE ONLY: OWNEOEDAGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application 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 will be in compliance with all Pertinent
provision of the Massachusetts State Pluming Code and Chapter 142 of the General Laws. �i
PLUMBERIGASFITTER NAME:'�4,6�/r�/VicI4/Addle- LICENSE#PZ-,r7or9/� / SIGNATURE
COMPANY NAME: oi.rid /h/c�,Q 4...,,l'4--i ADDRESS: --2-cV C /eery/x,4 Circle
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CITY: (,or7i"..-7"lyi,,i-T STATE:/jl ZIP:/1 -o 7-5 FAX:
TEL: CELL77 999 f'3 7 EMAIL: .�t1,t , t>e'Yh
MASTE ) JOURNEYMAt, JLP INSTALLER❑ CORPORATION 0# PARTNERSHIP❑# LLC 0#
E ni1r-/L 09.aZe-S : .d4LYe,n/Z4 itAIflc-L. , xei. c
.. z.12 0-
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