HomeMy WebLinkAboutBLDG-23-8789 SCN. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: YCLY)41 h Mk DATE Q.S-1/-Q3 PERIGIIT f�" I 7
JOBSITE ADDRESS 161 S P Yi A3 e.,{ OWNERS NAME:
GOWNER ADDRESS' TEL: FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL 121
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED:YES❑ Nog
APPLIANCES? FLOOR Bamt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE /
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
\n INFRARED HEATER
LABORATORY COCK
Wk MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
J ROOF TOP UNIT
Z TEST _
3 UNIT HEATER
nL UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability nnsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES Xi NO❑
If you have checked yam,please indicate the type of coverage by checit g the appropriate box below.
LIABILITY INSURANCE POUCY OTHER TYPE 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
hereby certify that all of the details and information I have submitted(or entered)regarding this appicadon are true and aspirate to the best of my
Knowledge end that all plumbing work and installations performed under the permit Issued for Ws application will with all Pertinent
provision of the Massachusetts State.Plumbing Code end Chapter 142 of the General Laws.
PLUMBERIGASFITTER NAME:DIYra-ciem f KvPoo ranrrA5LICENSE# 14/r{ SIGNATURE
COMPANY NAME: ADDRESS: l i d r f
CITY: W&x>L YayrnoV4j STATE: MA ZIP: O2673 FAX:
TEL: CELL SO 667`3 T63 EMAIL• k-ar Kyonglh vLhaai L co,--,
MASTER❑ JOURNEYMAN ITIf LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC p#
G hmiL A DAZE'5s: kapouk- y73-ha1-b-acI•co--1