HomeMy WebLinkAboutBLDG-20-004137 MASSACHUSEl'TS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,� CITY: S0&SC-K yA t}(ovh Mk DATE 1 f'Z1 2 Q PERMIT#✓, -CV
JOBSITE ADDRESS: 10 �y 2� b1I-Yr ID, OWNER'S NAME n
G OWNERADDRESS:2-(6(�.I �11' WO-' 1.i I TEL:Oa 427'7L99 FAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL al
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMRTED: YES❑ NO❑
APPLIANCES1 FLOOR-, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
SOUR
d BOOSTER
CONVERSION BURNER
-COOK STOVE
Ck DU ECT VENT HEATER
DRYER ---- ------ _
FIREPLACE
fRYOLAI'OR
FURNACE X
GENERATOR
GRILLE
Vti INFRARED HEATER
LABORATORY COCK , _
MAKEUP AIR UNIT
4 OVEN
POOL HEATER
ROOM!SPACE HEATER
-J ROOF TOP UNIT
.Z TEST
UNIT HEATER
1,4 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 ❑ NO Mil
If you have checked yu,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee Aggliajag the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,. ;that my signature on this permit application waives this requirement
/
SIGNA�WNEOR AGE T CHECK ONE ONLY: OWNER AGENT ❑
hereby certify that all of the details and information I have submitted Tor entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the pentdt Issued for Us appllcado wt be in ai Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PWMBERIGASFITTER NAME: G F CQ O( cl.A) v e t LICENSE#-2565 IG RE
COMPANY
NAME: €CT— ADDRESS: LA (1.15
!CITY: C4 1Y-N. y(A.W1 STATE/'14- ZIP.1`f L ler FAX:
TEL: s c c o cell: S4r1 c EMAIL: a re_ct c)(Ado bi2 c1m i ,co 'i
MASTER❑ JOURNEYMAN tig LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# R G Ci#E IV D
c m/,/C, 4DDt2ess Get g`G ehtl ff it (' , COH'
JAN9 7020
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