HomeMy WebLinkAboutBLDG-23-9709 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'= CITY: illtiK.dlr-T"W Mk DATE: i( 30 ..13 PERMIT# L- " 23 ?"-20
JOBSITE ADDRESS: X c Ev f'C& (.1•Y OWNER'S NAME Cx.• P1 Ffi HONEY
OWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q�
PRINT
I CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO I-
APPLIANCES-1 FLOOR-, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
- j BOOSTER
CONVERSION BURNER
t+' COOK STOVE
DIRECT VENT HEATER
O DRYER
c1 FIREPLACE
FRYOLATOR
• FURNACE
GENERATOR
s GRILLE
VI INFRARED HEATER
w LABORATORY COCK
MAKEUP AIR UNIT
4 OVEN
POOL HEATER
ROOM!SPACE HEATER
4 ROOF TOP UNIT
ft TEST
UNIT HEATER
-lyl UNVENTED ROOM HEATER
WATER HEATER
Oaf. r" rice, f
I. c-.riu 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES G-'N60
If you have checked Yid,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY fai 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 0
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 work and installations performed under the permit issued for this application will be In compliance with ail Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: d(E U'1 Al M 6Eiti1 N LICENSE# I I$fi - SIGNATURE
COMPANY NAME: M 6Et•#RrJ 114r d P.T4r-- ADDRESS: P.c. 3 S 833
CITY: 1 D S ro N STATE: M v4 ZIP: O:413 FAX
TEL: CELL: St K'„um al D4 O EMAIL 1 j Ct't L 004- Q_ /to {v{.a`L t • Cori
MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑#
c 4,/ ADINze•ss: r►t c- o - covet
N�OVV-3 0 2023
B Lt'SIMG DEPARTMENT
By: _