HomeMy WebLinkAboutBLDG-26-212 RECEIVED
M SS(CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Or 102B
CITY: rvv.o. , MA. DATE: '-1 L-1 1 4-Le, PERMIT#/5t1 2 2/Z
:JiLDING DEF-AkTgfrklo RESS 35 (--ay Smolt Ci OWNER'S NAME: Adar ,unt_s
OWNER ADDRESS: TEL: S"O fr-alp go?FAX:
TYPE OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW;0 RENOVATION:' REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0
APPLIANCES? FLOOR-. Barra 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE y
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
to INFRARED HEATER
Vt' LABORATORY COCK
MAKEUP AIR UNIT
c OVEN
POOL HEATER
ROOM/SPACE HEATER
J ROOF TOP UNIT
TEST
Z UNIT HEATER
14.1 UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO 0
If you have checked YES,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY'Egp OTHER TYPE INDEMNITY 0 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 minted)regarding thb appication are true and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit Issued for 1Ns application 11 be IrLcompllance with all Pert nent
provision of the Massachusetts State..Rumbbig Code and Chapter 142 of the General Laws. \`
PLUMBERJGASFITTCER NAME: K ev r t. r
Pr t-, LICENSE#I S 104 SIG RE a `
COMPANY NAME:JQry P lnL., xJ 111ADDRESS: y - -Unit)S4r.Cl L) 6i-90
CITY: (-‘.,a1anL STATE: triA ZIP. 04-31G FAX
TELT1 yI-9 is)-WJ1 CELL: 1Sl-'IOJ-ObSI EMAIL: c.,nl-ack6J sin-
MASTER%' JOURNEYMAN 0 LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC Q#3 S q Y
c h7/}vC, 0910 .eSS:
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