HomeMy WebLinkAboutG-18-4750 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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• JOBSITE ADDRESS `W 1, 12 tt t,R ' OWNER'S NAME La
G OWNER ADDRESS TEL' 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL Q RESIDENTIAL'®.
PRINT
CLEARLY NEW:® RENOVATION: REPLACEMENT:Q PLANS SUBMITTED: YES NOS_
APPLIANCES T FLOORS-' BSM 1 2 3 4 r 5 6 J 7 8 9 10 11 12 13 14
BOILER
BOOSTER •
CONVERSION BURNER '
COOK STOVE ' - —
•
DIRECT VENT HEATER 101.1111111110PlaafillitganitaitallitMINS,
DRYER 111.111'S 1111111.14 _
FIREPLACE : ,N 001111111111 , 1
FRYOLATOR
FURNACE MUR 44,01 -rata A<
GENERATOR ` 4
GRILLE �� �}I
11 V eta Laggistisswoma
INFRARED HEATER
LABORATORY COCKS • r4 _
MAKEUP AIR UNIT s
OVEN ns"w (� - +,
POOL HEATER F . . .
ROOM I SPACE HEATER 5 -
ROOF TOP UNIT 1111011a, S '
TEST t'rk .- .e,t >c l . • ' � , �. -
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UNIT HEATER _ " Agri @7 --
UNVENTED ROOM HEATER
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WATER OTHER HEATER ���
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES :4 NO Q
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY`(V OTHER TYPE INDEMNITY 0 • BOND Q
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Lan and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
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 lance with II ib nt provision of the
Massachusetts State Plumbing Cade and Chapter 142 of the General Laws. h
PLUMBER-GASFITTER NAME RD//Al D nAcaC UCENSE#ifflair IGNATURE
MP MGF 0 JP 0 JGF Q LPG;Q CORPORATION[3# PARTNERSHIP 0# _ LLC Q#
COMPANY NAME:184C gittica r, k f g, (4( ADDRESS laaST(Ill 2!L
CITY r// S STATE Furs ZIP (7a.6 3K TEL LcQR- 3u-97,c-cc {
FAX CELL g6fcS MAILI (0YI,4"P.P.e ogyn ttd-<."het 1
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