HomeMy WebLinkAboutBLDG-17-003896 I1RASSACHUSt S LIN€FORR!J APPLICATION FOR A PERIIINT TO PERFORM GAS Pi P a NG WORK
CITY s- y�
i r,,�G,:,e 17 t, MA. DATE e, 44/ AOJ PERVII T T=,%'x 4? --/ l
JOBSIr EADDRESS i.c/ OWNER'S NAME h.-p
t OWNER ADDRESS: "V'1'.J-� Sr . �� TEL f 1/ $--6p6 �,y FAX.. — I
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fir'';' OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL U RESIDEPfl1ALQ—
CLEP-_,L'f NEW:0 RENOVATION:1 1 REPLACEiiENT:J - PLANS SUBMI t YES 0 NO -'
FIXU I RES ? FLOOR— l Bemt 1 . -12 13 !- i 5 S f t ! 8 9 f 10 ' 11 f 12 ! 13 ) 14
1 1 I 1 _
BOO i I I I I I f i I f f l
COI vERSION BURN ! ► i - ! i f f f i I f f f f f
I COOK STOVE
DIFECTVENr HEAT_ER
FIREPLACE
iFRY0i ATOF
S FATORY COCKS
o
AIR UNIT
OVEN
POOL HEATER
ROOi i i SPACE HEATER
ROOT_TOE l JN!i
urtlT HE; I-
UNUEN.T-moo ROOM HEATER f I I I :71
WATER HEATER
Y
i I i i 1 I l i i 1 I I 1 1
i I I I I i
INSURA ICE COVERAGE
(have a current liability insurance policy or its substantial equtualarrt which meets the r owirnents of I'IGL_Oh.1'2 Yf.5 040 0
If you have checker YES.please indite the type of coverage t7`;checking the appropriate bo;C below. /`7Jf
LIABILITY INSURANCE ut UCY j i/ R 'PE INDEMNITY 0 BOND 0 /"7 ,IAN 3 t 1?O J
OTHER: .TYPE
OWNER'S INSURANCE rWP.WEt- I am aware that the licensee does nor.have the insurance coverage required by Chapter 142 of.the t
Massachusetts Gene al Laws,and that my signature on this parmii:application waives this requirement ^j
CHECK ONE ONLY: OWNER 1 i AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby cer dfy U1al all of the details and iniornaiion I have submitted(or entered)regarding this application are true and accurate to the best of my
Knov.ledge and that all plumbing work and inkallallons perfumed under the permit issued for this application will be in compliance with all Pertinent
provision of Vie.Massechuseks State Plumbing Code and Chapter 142 of the General Lao3.
PLUMIBERIG F I I IbP NAi4E: l 4-/777 gl=-iv V'LICENSE;t '72_7_1 SIGNh
COMPANY NAiv1 : 6:1- r�/lv�r cf— ����'� 7'rJvCi I ADDRESS: _S7`
. /l !STATE: /_"�1�'; ZIP: D 2 6 % FAX:
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VC ?CELL: S'*s 5a 70 EMAIL: rig-40A 3c'S y/J%v_r 7 6(3y-
i ER ErTIOLIRNEYMAN 0 L P INSTALLER❑ CORPORATION-D#f IP I HERSHIP!� l LLC 0 is) _ '