HomeMy WebLinkAboutBLDG-23-9553 P>AASACf�USETTa UNIFORM APPLICATION FOR A P.i r�— °�..:�_::aRMET M
i. ', �7 U PERFORM GAS FITTING WORK
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JOSSITE ADDRESS PERMIT#r �L3-QS3
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t �1VER'S NAME r c21:::
G OWNER ADDRESS
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TYPE OR •
)PEA OCCUPANCY TYPE RESIDENTIAL FAX
COMMERCIAL❑ EDUCATIONAL ❑
CLEARLY
[��`NEW:❑ RENoi/ATIOIV: ❑ REPLACEMENT: ❑ � /
APPLIANCES FLOORS_ PLANS SUBMITTED: YES I--NO❑
BOILER itairaiperaireas,BOOSTER t, 1,,CONVERSIOIV BURNERCOOK STO
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DIRECT VENT HEATER -
DRYER,
FIREPLACE v ��� Ell MINI
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all 11111 MN 1111111111111144M1=111111111111
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UNIT HEATER
UNVENTED ROOM HEATER -�` ��/-._
WATER HEATER
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I have a current IiabiBi ins INSURANCE COVERAGE -�--
� urance policy or its substantial -v-
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE dFt�C?VERAr equivalent which meets the requirements of�IGL. Ch.142
CHECKING THE APPROPRIATE nC??(DELt)►hr YES G NO ❑
LIABILITY INSURANCE POLICY
OWNER'S INSURANCE WAIVER: I am OTHER TYPE INDEMNITY ❑ BOND
aware that the licensee does not have the insurance coverage required by Chapter of the
Messechus.etts Genera!Laws,and that my signature on this permit application waives this requirement.
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.� SIGNATURE OF OWNER OR AGENT CHECKONE ONLY: OWNER
='�� I hereby certify that all of the details and information I have submitted or entered regardingthis � AGENT ❑
I h that all certify
plumbingthat
work P
and installations performed under the permit issued for this application will be in compliance
Massachusetts State PlumbingCode h s application are true and a curate to the best of my
`� and Chapter•142 of the G knowledge
p general Laws. P 'th all Pertinent provision of the
PLUMBER-r,AL qE
MPlayLP LICENSE#
SIGNATU
RE
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I ❑ CORPORATION 0¢f
COMPANY NAME ""' �� PARTNERSHIPEl#
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CITY OGRESS r ,_ 77*9AJ 1
STATE ZIP / 15,
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FAX T L .� `J 1 3
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