HomeMy WebLinkAboutBLDG-20-001947 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Vie CITY: , ,tip-y\ y a y-m MA. DATE: PERMIT# % b /?//7
JOBSITE ADDRESS: / ®o CC OWNER'S NAME Jeri(' Iti�-I/?
G OWNER ADDRESS: I�! •"' a I CO [s D d iQc4 TEL: -) `I.3 5.�g(35{Y FAX:SOff. 398 'it-
TYPE OR OCCUPANCY TYPE: f;oMMFRCIAI f"1 FnI irATInMAI f't RPCInE`WTIA1
I l iVi\
CLEARLY NEW;,( ' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOOR Bsmt 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
ki INFRARED HEATER
h LABORATORY COCK
ILIA VE1 ID AID 111.11T _
OVEN t
POOL HEATER
ROOM/SPACE HEATER
NI ROOF TOP UNIT
$ TEST
-.:2 UNIT HEATER
t,{1 UNVENTED ROOM HEATER
WATER HEATER
i
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 Tha,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ri6 OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:1 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 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 al Pertinent
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PLUMBER/GASFITTER NAME: U.gy--�/ V I V)ei - LICENSE# ( `3-1 q NALTUR
COMPANY NAME: ,J Cg J 4-( ? 11C \D 1 (1.ADDRESS: Li 741 W 6 UlS (v , `
CITY: 5. Vac (M d vt-itil STATE: N1 t, ZIP: (j,2 l.L 41 FAX
TEL: ' d 9 ''2 31 3 5 c( CELL S'a w1 EMAIL ck:' ear tl\ L)..3 Vl 1 , c
MAS tK LT JOURNEYMAN u LP INSTALLER 0 CORPORATION 6# PARTNERSHIP❑# tic
c ss : the ho„drh c�C► (a at),. co ry,