HomeMy WebLinkAboutBLDG-24-193 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
' CITY (� Crl10UT'�'�.,__.... ._..,. MA DATE i =7 i --)1 PERMIT# ?LD C - 2"t— l`I
JOBSITE ADDRESS h c oA924, OWNER'S NAME (Y- Q �
OWNER ADDRESS __. . TEL q . FAX _..
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES` NO
APPLIANCES 1 FLOORS-. BSM 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 R.F C E
FRYOLATOR
FURNACE I
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GENERATOR
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--_ --.- ---- - --- -- -" -. _.-.._.....1
GRILLE v
INFRARED HEATER Y; 6ulL---
LABORATORY COCKS �' l_r
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES NO
I IF YOU CHECKED YES,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 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
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Ryan Latour J LICENSE# 16691-M SIGNATURE
MP - MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC V# Ltc.50-
COMPANY NAME: Ryan Latour j ADDRESS 32 Hamilton Rd i
CITY Sturbridge 1 STATE MA JZIP101566 LTEL 774-289-2487
FAX I CELL 7742754527 EMAIL permits@latourpc.com