HomeMy WebLinkAboutBLDG-20-005751 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: 1,j VP-11/ r1 MA. DATE: PERMIT#ii iO 4"CVy�3/
j VP-11/V‘ � /"
,^ JOBSITE ADDRESS: .5 S Ytw 14 I cJ OWNER'S NAME: uq
G OWNER ADDRESS: t rot-ILL 1 ). t,v t/.' %oTEL: )49lC C FAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL Cl RESIDENTIAL 0
PRINT
CLEARLY NEW;❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES-] NO❑
APPLIANCES-1 FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER _ _
CONVERSION BURNER /
COOK STOVE V
DIRECT VENT HEATER
DRYER
—
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE _
tyl INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT _
OVEN
POOL HEATER
ROOM 1 SPACE HEATER
I ROOF TOP UNIT
TEST
UNIT HEATER
14.1 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 [Z340 0
If you have 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 0 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 appllcati will In compliance 7,all Pertinent
provision of the Massachusetts Stat urn ' g Co and C pter 142 of the General Laws. `��(Rig
/ ,�PLUMBER/GASFITTE AME: LICENSE#l>f'7 1- /- 1PNA ' ./
COMPANY NAME: its %! ADDRESS: 3 -k44/ L)''Z.fre
CITY: f L STATE:t � � ZIP:C & FAX:
TEL: t,' — ,°c CELL/ '7// -(.'`' / EMAIL:
MASTER[JOURNEYMAN LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
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