HomeMy WebLinkAboutMiscellaneous - 140 HICKORY HILL ROAD 4/30/2018 (9) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: MA. DATE: PERMIT#
JOBSITEADDRESS: ii
� OWNER'S NAME:
GOWNER ADDRESS:�E`� , �I,� TEL:7 '2>`L` 3 FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES El NO
APPLIANCES-1 FLOOR Bsmt 1 2 31 1 4 1 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR I
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN I
POOL HEATER
i
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial egtllivalent which meets the requirements of MGL.Ch.142 YES OKN0 ❑
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,Joes not have the insurance coverage required by Chapter 142 of the.
Massachusetts General Laws,and that my signature on this p6 rmit 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 work and installations performed Ender the permit issued for this application will be in compliance all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME:Mar Q ,Zb LICENSE# J 35S 19-IGNATLIRE
COMPANY NAME: ADDRESS:-3--i �6ncst ST"
CITY: STATE: A ZIP: FAX:
%)$ 97 Er
TEL: Z/ 5 3 CELL: 9 36~ ZI5 3 EMAIL:
MASTER JOURNEYMAN❑ LP INSTALLER❑ CORP,ORATION PARTNERSHIP❑# LLC❑#
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