HomeMy WebLinkAboutBLDG-18-004044 /7?Ar° /019R c e/
_.MASSACHUSETTS UNIFORM!APPLICATION FOR A PERMIT TO PERFORM GAS I-1 11NG WORK
- L, - CITY i Town of '/AR m() U 1 H iMA DATE. ^ t i L pEuirr#/*AS-Vg-cr'4'6'/4/
(� ' JOBSI TE ADDRESS! I/) -rr'e2�n or (2ri. I OWNER'S NAME, 1►/ .'�c c . 1�,I I 4
lir OWNER ADDRESS 1 '__ _ j TEl %A L 716 • QTi,O'FAX;. . 4
TYPE OR OCCUPANCY TYPE COMMERCIAL Li F►hICATIONAL j RESIDENTIAL
PRINT
CLEARLY NEW:Li RENOVATION:gi REPLACEMENT:0 PLANS SUBMIi itu: YES NOD
APPLIANCES 1 FLOORS-4 B5M 1 2 3 4 5 6 7 8 9 10 1f 12 13 14
BOILER - P ' 1 TP _ i ..- ,„ opt i Aim
BOOSTER ;_ ,� 1 �.._, -.. .-......:1—.. - - ..,<
CONVERSION BURNER ' z ___ _ '
COOK STOVE i3 �- _ nw — - -
DIRECT.VENTHEATER
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DRYER pinjump ' ti 1� !i
FIREPLACE liar -.101111111111.111
FRYOLATOR
1 RNACE )...;::-. aft si aM � 1M
0 • • n EIRATOR I r n r=,a.na.MR_.. `1� I� Illy
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TORY COCKS . r• x••
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POOL N TER •
6 i !!THEATER
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UNVENTED ROOM HEATER
WATER EATER _;RW ,l�i `INN .
OTHER _ iff OM=Emir IMF Mr
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1110,...aillinananna 0•E.
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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 O 9
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY Ed 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 9 AGENT El
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitbed or entered regarding this appliica5on are true and -... _i- tc+ a . ., my imowledge
and that ail plumbing work and instasiatons performed under the permit issued for this application will be in compliance ° ant. • slam of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME,kph;n fr CB C:Ap . LICENSE 141 Rya C)1 - SIG RE
MP�MGF 0 JP 0 JGF L LPGI 0 CORPORATION fait c3 8 6S C !PARTNERSHIP Eal 1 liC r-
COMPANY NAME)Ciz,,,,•MLEri a e. Plum 4 )—Lc cJADDRESS L 1 I L, nine Palk
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CITY I W. Yi_.r a.�-4, • i STATE=7JP! Ocu.7.3 fTEL (5a&,) -rig- 4 554 I •
F r6a)740-678g CELL 4364-3441E tAILI k'(Y Cp k V rn I) t fOr r_G.S-I r�e 4
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