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HomeMy WebLinkAboutBLDG-24-277 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Z n . ?,= CITY: /////j(/Lf/1-, MA. DATE ,c/-d PERMIT#QZt)G Z''- �7'7 G JOBSITE ADDRESS: // (---Si/a,v /,,s OWNER'S NAME: /�I) �.4oti vn/{' OWNER ADDRESS* Si151/71'/c TEL:fUc9-737d9f/dFAX: j t TPP E TR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO,21' APPLIANCESI FLOOR-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER -1 COOK STOVE q DIRECT VENT HEATER DRYER _ FIREPLACE FRYOLATOR (./ FURNACE UGENERATOR . GRILLE INFRARED HEATER W LABORATORY COCK . MAKEUP AIR UNIT 4Z) ---------74:i-Ai D \.. POOL HEATER R F iv.E ROOM/SPACE HEATER r \I ROOF TOP UNIT I ' TEST ice ��;/,-- i ! 11A`4 012024 UNIT HEATER i 14.1 UNVENTED ROOM HEATER o n i t hG- !'''u-1 Ni N' ' WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO 0 If you have checked Yam,please Indicate the type of coverage/ by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 0 AGENT❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this appication are true and accurate•the best o•y Knowledge and that all plumbing work and installations performed under the permit Issued for this application J n.•mplen.=with all Pe' .it provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTERNAM ///en,,J1 LICENSE# 7..?/ ` E:� SIfige:T3�� COMPANY NAME: ,�-/sy' liv(' fro fQ.r� ADDRESS: 'am r!/' SA CITY: 81,-/ A1/1-PPC., -Af- (STATE:/ ' ZIP:©d ' K FAX: TEL./ J-b ,''(3( CELL: , (9:sD /9 I'8 EMAIL: MASTER 0 JOURNEYMAN❑ LP INSTALLER CORPORATION❑# PARTNERSHIP❑# LLC❑# c/rim c., ADA2ass:.