HomeMy WebLinkAboutBLDG-23-9785 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: J O L A"'\ fr rev, vim► MA. DATE (Z/r 10-3 PERMIT#660 G-23-4 7 '
JOBSITE ADDRESS: 15 C e boa,.d l col OWNER'S NAME: 6 K t/ i F
G OWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW: RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
APPLIANCES3 FLOOR-, Bsmt 1 2 3 4 5 6 7 8 8 10 11 12 13 14
BOLER
BOOSTER
CONVERSION BURNER
COOK STOVE
DST VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE _ 1
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
SW MAKEUP AIR UNIT
`*l OVEN
POOLHEATER
ROOM!SPACE HEATER
J ROOFTOP UNIT
t TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
(TRANCE COVERAGE -
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Chr.142 YES [ NO ❑
If you have checked!Et please indicate the type of coverage by checking the appropriate box below.
s LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND ❑
pOWNER'S INSURANCE WAIVER;I am aware that the licensee does not have the insurance coverage reguked by Chapter 142 of the
(1_. Massachusetts General Laws,and that my signature on this Permit application this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
.}- SIGNATURE OF OWNER OR AGENT
d _
e hereby certify that all of the details and information I have submitted(or entered)regarding this application are true a ccurate to of my
Knowledge and that all plumbing work and installations performed under the permit issued for ttds application will be pilance all Pertinent
provision of the Massachusefts State.Pkaubtng Code and Chapter 142 of the General Laws.
ter PLUMBER/GASFITTER NAME: M"C hC.d pi t?r-€c LICENSE#1 Q SIGNATURE
3 COMPANY NAME: pf r C P. l err b i n I hL ADDRESS: c( ((cki CC e S w(Ai
- cry:Lv e S} 1(ri r n'U v1n-. STATE:144 4 ZIP: 6 ?3 FAX:
0 TEL:7 7`I. 7 1 3 a a\cELL _ EMAIL: p l e rce_p/L'e.,6 I n)5e:vtct-C yM k 1. c{,••1
MASTER[ JOURNEYMAN❑ LP INSTALLER 0 CORPORATION❑# PARTNERSHIP 0# MC❑#
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