HomeMy WebLinkAboutBLDG-19-004092 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PE GA3 FITTING WORK
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CITY: _ v MA DATE: / '� / 1. PERMIT#/ P7-0t 00'ri
JOBSITE ADORES&& /2 ,z,t 1 OWNER'S NAM:r/
G OWNER ADDRESS: TEL J D 6r-X(ILFAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[r
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
APPLIANCES-1 FLOOR-, Bor* 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 4
BOOSTER
CONVERSION BURNER -
COOK STOVE
DRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRLLE
INFRARED HEATER
kLABORATORY COCK
R MAKE AIR UN '',
OVEN 1 -
POOL HEATER
ROOM I SPACE HEATER • L IpN +?
J ROOF TOP UNIT f
TEST e�i�:_��rv� �,t PA'""?? rr�[��Ss
UNIT HEATER
14.1 UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requkements of MGL.Ch.142 YES ErNo ❑
If you have checked please indicate the type of coverage checking the appropriate box below.
LIABILITY INSURANCE POLICY met
OTHER TYPE INDEMNITY 0 BOLA 0
OWNER'S INSURANCE WAIVER:I am El ware re 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 Nghm this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby oerify that all of the details and informaton I have submitted*entered)regarding this application are true a• : :to of
Knowledge end that all plumbing vrork and Installations performed under the permit issued for this application �, .. ._ at Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General laws.
PLUMBERIGASFITTER NAME Ci/ /4 r/�c.� uCENSE# //3 2-4) RE
COMPANY NAME: /0;4,/ fb"i/ z- L - ADDRESS: ,-6)6) - �C J3 5L
CITY: ?( AA/ STATE: ZIP. L.0 J / FAX:
TEL: CELL: )123 7.ricL 3 EMAIL'
MASTER[JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
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