HomeMy WebLinkAboutG-19-905 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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=Jti_ : CITY )/494Thv7/O0/-1 MA DATE /715.4501 PERMIT#/34!6'-/9—WQflt
JOBSITEADDRESS /6 . ZAv&su ot to-tic. OWNER'S NAME /`/'arc i J c 0111 Af
G OWNER ADDRESS TEL FAX r
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 • EDUCATIONAL 0 RESIDENTIAL[' / So , oo
PRINT /
CLEARLY NEW:[ RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO[P'
APPLIANCES? FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 ' 13
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR • •
FURNACE
GENERATOR DUffr & 1
GRILLE
INFRARED HEATER •
LABORATORY COCKS
MAKEUP AIR UNIT t- 0=
OVEN
POOL HEATER . c- I
ROOM I SPACE HEATER , . \'�� t
ROOFTOP UNIT � j '�
TEST • \ `
UNIT HEATER t \ • N��✓ /
UNVENTED ROOM HEATER \ "` " _-
WATER HEATER \
OTHER
INSURANCE COVERAGE
I have a current Jiability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES 2 .10 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IVB OTHER TYPE INDEMNITY 0 BOND 0
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 ❑
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 knowledg
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ---
PLUMBER-GASFITTER NAME .,� LICENSE#11577 SIGNATURE
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MP['MGF 0 JP❑ JGF 0 LPG!0 CORPORATION e PARTNERSHIP 0# LLC❑#
COMPANY NAME Cabe Cod Fium4rrice 1-1477 ADDRESS f.a. daS 42.1
CITY S be-ay STATE✓t14- ZIP_n26( o TEL Sot- 31F -2zzP
FAX CELL EMAIL /
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