HomeMy WebLinkAboutBLDG-23-9706 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
zf• =r�
Ti :. CITY; yu -(vti•;. otzie MA. DATE i t 1 a4 `,. 3 PERMIT#gc DG Z7-9'7C6
JOBSITE ADDRESS:141 RCL.&v b‘n(ee-i" (`AA., loA OWNER'S NAME: A-elow2-' W w-St e.A✓
GOWNER ADDRESS:S e t"CA r TEL: YI 314-7773 FAX: 3.3`t`I,g
TYPE OR OCCUPANCY TYPE: COMMERCIAL" EDUCATIONAL D RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:jr 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
<✓j INFRARED HEATER
LABORATORY COCK _ --- w'
MAKEUP AIR UNIT I H. E r 1 v i.: D
-'4. OVEN
POOL HEATER NOVy�
ROOM/SPACEHEATER V" `) 2�4�
.I ROOF TOP UNIT
TEST 3UILDIIVG 1IF-PART\AFMT,
UNIT HEATER ;
t,U 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 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 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 ❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true andfi rat the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this appllcationwA roll ce with all Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTER NAME:S `e .ft."7 rim LICENSE#0''�'`I g SIGNATURE
COMPANYNAME:t•�td.v ) eu,�,,�h1L J ADDRESS: W. VLQa cirCJLZ,
CITY:...-r-ieNYcv-(..tL1 1% STATE: 0- ZIP: 0a6toy FAX g-A- 3 t`{-g.4 S-10
TEL: ' - 3g1- 777' CELL: 11)`1ql 7-77c EMAIL: tn,seo-e-A-ruys-1 E (2fLv,v.Skck.'..c-p,-A
MASTER I?X JOURNEYMAN❑ LP INSTALLER❑ CORPORATION[ `3A IC PARTNERSHIP❑# LLC[]#
c/i,/L, ADZ2&ss 1 r sr v,.J ci, P y,t'te-s14.).fr