HomeMy WebLinkAboutBDG-16-004450 MASSAGN4#SETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1; -Ctrr. PERMIT# /i-/.�G'/(o ct) '
— i -,lei o f ( MA DATE _ oZ /5-�j� ( �y
G JOBiI DRiSS 19c /, /u� ,c,c.A OWNER'S NAME 72 y /"If)-7f/c= i
I L D I N c� d : JO A ./i arc.✓ /ce,✓f/Q b,,, TEL: Ell- /2/- 77 FAX:
PRINT' kY4) —"OCCUFANCYTYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMI t i ED: YES 0 NO 0-
FIXUTRES Z FLOOR-. I Bsmt [ 1 ' 2 3 I 4 5 I 6 _ 7 B - 9 . 10 11 _ 12 13 14
BOILER
BOOSTER t_
CONVERSION BURNER _
COOK STOVE _ i
DIRECT VENT HEATER _
DRYER _
I FIREPLACE
FRYOLATOR I
IFFURNACE I - I
GENERATOR
GRILLE
LABORATORY COCKS I _
MAKEUP AIR UNIT I I
OVEN
POOL HEATER I I _ -
ROOM I SPACE HEATER I I j
ROOF TOP UNIT
TEST _ I -
UNIT HEATER I ,
[ UNVENTED ROOM HEATER
WATER HEATER 1 T I
F- ' I 1- ' -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES �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 ❑
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 worst and installations performed under the permit Issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFfTTER NAME: VA-o" Gi;4,v6/e-Gpaibil..LICENSE# 977?t SIGNATURE
COMPANY NAME s? CQ 3' P/j n.7 . ,)vG- 1--/,--),9--7`/it/ ADDRESS: -/k-g-/1'/t)--A,-cc?:- ✓ 77%?•c
•
CITY: /(J�-v,v,r®oc - 77 STATE: ZIP: D, 6,J7 FAX: 5f-79VG VS/
TEL S'Z9 '•---.7 j,-'-•J8(/6 (CELL: Se- s c --20 Fq EMAIL: /'4i-iii e 3,)SiO/u r 7 61 hy. /l e 7.-
MASTER EIOURNEYMAN❑ LP INSTALLER❑ CORPORATION El# !PARTNERSHIP❑# LLC❑# 1
L,'M