HomeMy WebLinkAboutG-19-095 MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTINGWORK
cm,' •7 a-a.m o L/71-1 MMA DATE 1 (C I I $ PERMIT#n6%/1/44c0a9C
JOBSITEADDRESS 3`? QE'I0 la11t7 OWNER'S NAME 1-611(-rtr \/Ew ute-s
OWNER ADDRESS TEL"77 Y- 3 La-ca 6S-FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDU
EDUCATIONAL 0 RESIDEJTIALPRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:I, PLANS SUBMI I I LU: YES 0 NO 0
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I.
DIRECT VENT HEATER -
DRYER -
FIREPLACE
FRYOLATOR
FURNACE I . '
' GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS I E E 6 C F. c., '
MAKEUP AIR UNIT I 1 I
OVEN
1, II II Qpiq i a
POOL HEATER ' 9
ROOM/SPAC'.E HEATER ' ' ------ 7' -. ' H
ROOF TOP UNIT `
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER /
OTHER
INSURANCE COVERAGE '
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY l 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
`t;
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
IA lf!! / C34( FEE: S PERMIT II �rC/�qT AI
Y PLAN REVIEW NOTES PC
. —R/A 7 ' /f 9 /7