HomeMy WebLinkAboutBLDG-24-763 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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; CITY: Y/41---111t,V 7C� MA. DATE: (z r3 Z�PERMIT if - t)y 2c 3
JOBSITE ADDRESS:. 6 &- I `5 I IWNER' NAME:_
G OWNER ADDRESS: TEL: FAX:_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL W--------
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CLEARLY NEW: RENOVATION:0 REPLACEMENT:IZ./— PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-1 FLOOR--4 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
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FRYOLATOR ,
FURNACE _
GENERATOR _ _
GRILLE _ - , _
vt} INFRARED HEATER _ _ _
W LABORATORY COCK _ _
MAKEUP AIR UNIT
OVEN _ _ _
POOL HEATER R E. C F � .. ,
ROOM!SPACE HEATER -.--
NI ROOF TOP UNIT - �. . . .
TEST
UNIT-HEATER EC 1. 2024
c u UNVENTED ROOM HEATER _ _ — 136 I C I N c; 11 M{,<MI:R-
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 1----‘-::]
If you have checked YES,please indicate the type of coverage�/by checking the appropriate box below.
LIABILITY INSURANCE POUCY [t' 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 ❑ 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 installati.A,: .: •med under the permit issued for this application will n compliance with ail Per cent
provision of the Massachusetts State Plumbing •.'°"+d Chapter 142 of the General Laws. '
PLUMBERIGASFITTEER AME:, 41 ff41ZUjI-f N t 1 / SIGNATURE
COMPANY NAME: [ TO1,64KY /t .ADDRESS: 2 ) _
CITY: betn-HA STATE: elfin-ZIP: 0 2 7�FAX: '
TEI � 3f !l CELL: EMAIL:b d'7 C (C 11uip/47-11 a L.O(6.s Mc
MASTER 0 JOURNEYMAN 0 LP INSTALLER❑ CORPORATION 0# PARTNERSHIP 0# At cD#
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