HomeMy WebLinkAboutBLDG-19-001774 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 313 Wil tA2 S 9�lAA OWNERS NAME 3 okn star G Sup? 1y
G OWNER ADDRESS TEL FAX•
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW:0 RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS-1 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER __ —
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR I Ce F F -BILL' —
GRILLE 1 ki
INFRARED HEATER 1 -- I f
LABORATORY COCKS lk.. s�P a P zeta i
MAIUP AIR UNIT
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POOL HEATER • ey
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST .. _._
UNIT HEATER
INVENTED ROOM HEATER
WATER 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 NO ❑
IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA 81 CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L3 OTHER TYPE II4DEMNITY 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
3 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 ,e to e b tt of y fr wledge
- and that all plumbing work and installations performed under the permit issued for this application will be in oomph- all P ne s i
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /)
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PLUMB ER-GASFITTE NAME LICENSE#38YZ SIGNATURE
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0 JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP❑4 4::t"
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COMPANY NAME r r l A�$S TIM SR��I CE ADDRESS g I C A q \ 1 "rpt Y/IR 0
CITY G�'e.ln�SAev- STATE'v 1 V ZIP O 263 I TEL/Co f,b . 6 9 3j S
FAX CELL 22Y2l (0 INaI EMAIL 6p leMOEN 83l� cco/vvwwsI ,� I
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