HomeMy WebLinkAboutBLDG-20-003114 S` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`a t I• CITY; O ) MA. DATE /^ 5 /1 PERMIT#/ LOU,& J
G JOBSITE ADDRESS: 9 `/r¢ ' 1i t i 1 CA
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OWNER ADDRESS: 2) -.a e S} TEL: 7�7 /1 P) FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:, PLANS SUBMITTED: YES El NO❑
APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 - 14
iI BOILER
v BOOSTER
iCONVERSION BURNER
c\, COOK STOVE
U DIRECT VENT HEATER
c- DRYER
-0 FIREPLACE
13-3 FRYOLATOR
1-alFURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
t MAKEUP AIR UNIT I I
OVEN T INi d i r
' POOL HEATER
ROOM I SPACE HEATER
•J ROOF TOP UNIT �" �t: kTi,',n''
fi TEST ---..- __
UNIT HEATER
to UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
WNE S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mas chustitts General Laws, at�my signature or.this permit application waives this requirement j
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CHECK ONE ONLY: OWNER 4, AGENT
RE OF 0 ER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and a ate to the best of my
Knowledge and'that all plumbing work and installations performed under the permit issued for this appllcato it I ance with all Pertinent
provision of/the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME:, Laes-4)— LICENSE# . .....457' SIGNAT E
COMPANY NAME: CC ' ADDRESS: �v /I/e,7M y
CITY: S h(4 i 1)r 4-4 STATE: lit ZIP: 6;;27..)/ FAX:
TEL: CELL: (7)// t.36 .5---,,, 2 EMAIL: -D 2/J fr 6 'Di,cIJ Art J/4 , div
MASTER e JOURNEYMAN 0 LP INSTALLER❑ CORPORATION 0# PARTNERSHIP El# LLC❑#