HomeMy WebLinkAboutBLDG-23-9933 d*
�` •SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
..- �r✓ ! I .t2t, �`� Mk DATE $i21 '2 PERMIT#UZ. C� L3 1y?3
AUG 2f313t0:, :ADDRESS: �� �hY�c � = OWNER'S NAME: �JC k���2�r
O,'��R 'DRESS: S .— TEL:
PARTM T' FAX:
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7 . FA CY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El,,
CLEARLY NEWS. RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES RI, NO❑
APPLIANCES1 FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER i
BOOSTER
CONVERSION BURNER
COOK STOVE I '
DIRECT VENT HEATER
DRYER
FIREPLACE _ 1
FRYOLATOR
FURNACE
GENERATOR l
GRILLE
ti INFRARED HEATER
_LABORATORY COCK
cs MAKEUP AIR UNIT
OVEN .
POOL HEATER
ROOM/SPACE HEATER
..1 ROOF TOP UNIT
TEST I
UNIT HEATER
t tj UNVENTED ROOM HEATER
WATER HEATER •
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q.,NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that all of the details and information I have submitted(or entered)regarding this application are tni 'fb t3 best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will be I all Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 42 of a General Laws.
PLUMBER/GASFITTER NAME: C� . S LICENSE# t o SIGNATURE
COMPANY NAME:V VVr -4,4 �,
-( ,� c� :ADDRESS: L>� S � �p� •=�l)l?J�`�C,� �/�
CITY: k LOS STATE: li ZIP: O)3
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FAX:
TEL: CELL: '7r1_ 72-Z _ LS EMAIL: 4E+� A 0 eC� TA1/2„ -
MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION gii (..m$e PARTNERSHIP El# LLC❑#
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