HomeMy WebLinkAboutG-19-1799 arl
i. z` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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GIJOBSITEADDRESS 13 4/cith //2112 (OWNER'S NAME
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OWNER ADDRESS Luny ITO5-br?•liaa-ati o 'FAX) ' I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
• PRINT D RESIDENTIAL RI
CLEARLY NEW:
Le RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO[I✓
BOILER
APPLIANCES 1 FLOORS-4 ESM 1 2 3 4 5
5 7 8 9 10 � :_..� 14
BOOSTER
11 12 13
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CONVERSION BURNER �
Sir
COOK STOVE
1 - 7 Y.
DIRECT VENT HEATER i_ W
DRYER f � �{
FIREPLACE i� ( f
FRYOLATOR - --- 1
FURNACE <_. I )'. ', 1,
GENERATOR SII __._.�.___T,
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GRILLE �GRILLEEDHEATER IFi. Il it ]' 1
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LABORATORY COCKS r '-1 -
MAKEUP AIR UNIT f I- t`
POOL /EAACEHEATER •
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POOL HEATER � 1111111 I II �� �I �, � �
ROOF TOP UNITim ,� _ )({ r f ! P
TEST f� r3 n:"c 2 IPA crMc IT ! h`
HEATER --
UNIT _
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UNVENTED ROOM HEATER
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WATER ,� i1_4�� �i .- ,' - _.__.-,�
OTHER i -- I ��
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INSURANCE
I have a current abill Insurance policy or Its substantial equivalent which mea s the requirements of MGL Ch.142 YES [F. R) 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNMassachusetts
General Laws,and that my signature oS INSURANCE WAIVER:I am aware that the n this pensee does not rmit applicatioave n waives this requirement.nsurance required by Chapter 142 of the
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑
Iand that all hereby certify that awork and ll of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
Massachusetts State Plumbing installations
ode aid Chapter performed
2 off the Geder the neral Laws ad for this application will be in compliancewith I Pe Inert provision of the
PLUMBER-GASFITTER_ NAME I1.5kV" W act0 I LICENSE#I "b j SIGNATURE
MP0 MGFLIQ JP JGF0 LPGI❑ CORPORATIOND#I IPARTNERSHIP[j#I ILLC D#I
COMPANY NAME �,„„ �,, ( [h , m o,(�w�-,a-{ lskADDRESS I 1
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CITY .nyl, I STATE jJ,j -ZIPI02L244. j� TEL 51?-cl7-7-$-
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