HomeMy WebLinkAboutBLDG-23-9547 CJ
�, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`+v= CITY: C— ( 4 MA DATE I `�. PE Q 2 3• '5 y,
_ ` w "' � 1 ` RMIT 7
JOBSITE ADDRES&T 7 TC2�I _ 1-4A-0 JWNER'S NAME:"CC—K.)t.t '7N\C
GOWNER ADDRESS: 44U1's' TELFN-�'��t, ' X:
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL El
PRINT �,/
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES❑ NO Ud
9- APPLIANCES? FLOOR-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
cf�J BOILER
BOOSTER
/) CONVERSION BURNER
L. COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
C FURNACE - .
GENERATOR
GRILLE
IA INFRARED HEATER —
t1 LABORATORY COCK
MAKEUP AIR UNIT
4,1 OVEN
qPOOL HEATER t— (s F I ' F
ROOM/SPACE HEATER
NI ROOF TOP UNIT nit/G/ j Cell)
2 TEST '�L) D`r 2J1.1
:2 UNIT HEATER
tL UNVENTED ROOM HEATER ii uinitir_nFPAvTcfFaT
WATER HEATER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO❑
If you have checked Y1,4,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY Zr OTHER TYPE INDEMNITY❑ 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.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this apptcation are true and accu to-the best off any
Kprovision
and thatall Massachusetts
work and installations d p undero the permit Lawfor this appliction wit all • nt
provision of the Maasadtusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER/GASFITTERNAME:�iJh )cr Nam)3j LICENSE#r j�p L_
COMPANY NAME:�� l ... `` ADDRESS:1 VI l h CV1�k)] a
CITY:`IliNr�Cyr cC STATE: 1I,..‘A ZIP.i�r�443-1.C\ FAX:
TEL 1(—le?- — LL: EMAIL:
MASTER❑ JOURNEYMAN LP INSTALLER❑ CORPORATION 0# PARTNERSHIP❑# LLC❑#
E/?IiL. 0 9,02eSS:� ►l �i;�l,f � n i2a , i 11..b\