HomeMy WebLinkAboutBLDG-24-468 l` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY: ' /���`i MA. - DATE: 8/7/�t-i PERMIT( & DO -Z't— L1 f<'Y
JOBSITE ADDRESS: ' . i�"1� ( ‹,/ OWNER'S NAME: Al'' "`-f-1
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OWNER ADDRESS: L TEL: / AX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ 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 ,
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR •
FURNACE j ,
GENERATOR
GRILLE
V} INFRARED HEATER 1
1l LABORATORY COCK R E C � 1 \ J
MAKEUP AIR UNIT 1 t
OVEN ,
' POOL HEATER \,4/AtiG 07 2 G 9 i
ROOM/SPACE HEATER
---.1 ROOF TOP UNIT a NG DEPARTMENT
TEST gUtt_n
2 UNIT HEATER —'"`
i 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 YE O E
If you have checked YES,please indicate the type of coverage b ecking 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
Massachus neral Laws,and that my signature D this permit application waives this requirement. _
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CHECK ONE ONLY: OWNER 0 AGENT LT
NATURE 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 application will be In .ance with all Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142 f the General Laws. c,.. —`.J j�y,� �
PLUMBER/GASFITTER NAME: /5 L/rr - ( o erf f LICENSE#/ dye_ SIGNATURE
COMPANY NAME: 0 k'✓ 4- -(/t 4' '/4(ADDRESS: 5— Co PO �f
CITY: /1 d —au - /!�STATE: ,W4 ZIP: 0 a7 6 4 FAX:
TEL: CELL: EMAIL:
MASTE -j JOURNEYMAN❑ LP INSTALLER❑ CORPORATION 0# 4/6a PARTNERSHIP E# LLC❑#
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