HomeMy WebLinkAboutBLDG-19-004254 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
=.sttrh=
aITLE--_--. CITY _,.V4,1-iio R MA DATE I7...1(053,(9)cl PERMIT# 4146 19-61O l/ Pik
JOBSITE ADDRESS Z 7 .f rryL,awe,, ....., ,1- OWNER'S NAME � vA re'/ G-e„,:, ,.,... _.,
GOWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL ,, ED CATIONAL ; RESIDENTIAL
PRINT
CLEARLY NEW: , RENOVATION: REPLACEMENT: ,,; PLANS SUBMITTED: YES NO „,;
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER 777-7"...'' I 1
DRYER '
FIREPLACE p"... ,
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER '_
LABORATORY COCKS ";
tW '
MAKEUP AIR UNIT �... .
OVEN
POOL HEATER . „vr; _,
ROOM 1 SPACE HEATER - '
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO
I IF YOU 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
I 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 compliance with all Fert'nent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Sean Hanrahan LICENSE# 15822 SIGNATURE
MP i MGF JP JGF LPGI CORPORATION # PARTNERSHIP # LLC
COMPANY NAME: Sean Hanrahan Plumbing and Heating ADDRESS PO BOX 688
CITY Centerville STATE MA ZIP 02632 TEL 774-238-0286
FAX 508-775-4615 CELL same EMAIL hanrahanplumbing email com
c"' V