HomeMy WebLinkAboutGas Water Heater/BLDP-23-8508 - BLDP-23-8508 387 MASSACHUSET'TS UNIFORM APPLICATION FOR A PENT TO PERFORM GAS FITTING WORK
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INSURANCE COVERAGE
I have a current liatilit insurance policy or its substantial equivalent Which meets the requirements of MOL.Ch.142 YES li NO 0
If you have checked yfa,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY
OTHER TYPE INDEMNITY ❑ BOND Cl
OWNER'S INSURANCE WAIVER:I am aware that thero icenseeerm t ao have thtion incur nhe coverage
regquired.by Chapter 142 of the
Massachusetts General Laws,and that my signatu P CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT :,,_
regarding this application are true and a rate the bee ��y
Itionion 1 ea In a pliant � •'••
hereby certify that all of the details and information 1 have submitted(or entered)re quad or this application a
Knowledge and that all plumbing work and installations performed under the permit �.
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. SIGNA RE `
V, .\a '1Y-,� � j� LICENSE#. 1 i
PLUMBERIGASFITTERNAME: r t�►� t • ��,��_� CCt ADDRESS: _
COMPANY NAME: Qom^ � a��
• STATE: ZIP: �` � FAX:5
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CITY: Q .`�'
A.u'1'1 Mi.EMAIL:
TEL:S L CELL: _... ._ LLC 0#
� PARTNERSHIP[]#____---
_/ LP INSTALLER❑. CORPORATION L'�1# la ---
MASTER L�' �G1IRNEYMAN 0
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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7 g CITY yar m ou -h MA DATE 'S 8• PERMIT#VLbPT 2 - SG/
� JOBSITE ADDRESS 440 Nat.LhalA h t RC)• OWNER'S NAMECIAticiaiczak
OWNER ADDRESS TELSJ( (off' -T• FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[r PLANS SUBMITTED: YES❑ NO[?!--.
FIXTURES 1 FLOOR--* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER •
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I
WATER PIPING
OTHER
•
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Y( NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑
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 ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this application are true an ccur e of y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compile with I pro ion of th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. " I
PLUMBER'S NAME Ee:i rr1 farnha:Al LICENSE# 116 0 IGNATURE
MP 2r JP❑ CORPORATION[r#. lo92 C PARTNERSHIP 0# () LLC❑#
COMPANY NAME Sa 4- ihcce, -lken 5 kn3 4 Coin, ADDRESS 7 lvh Cr
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CITY Sou -k Vcirt'vict)t STATE'I- ZIP (1%04.4 TEL 5O 39g-L9p3
FAX 5 O - 4-toO— (eS I CELL EMAIL -• -- - - 7-- _ �- -
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