HomeMy WebLinkAboutG-19-2399 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Wirer Ir CITY \IAJ'Ynbl MA DATEta PERMIT# n1J'/9-0a2
JOBSITE ADDRESSZI "Ir AVICOEP .1S W A y • OWNER'S N.AMEIMCC1140 I1A -IML.41k
OWNER ADDRESS TEL FAX
TYPE
OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES 0 NO 0 I
APPLIANCES 1 FLOORS-. BSM 1 2 3 I 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY NOOKS
KECE * - —�
MAKEUP AIR UNIT
OVEN 22 2018 .
POOL HEATER
• Fp
ROOM I SPACE HEATER
ROOF TOP UNIT �`r7rlctiT
TEBTaY-
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UNIT HEATER
LINVENTED 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 YE&-® NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLlett OTHER TYPE INDEMNITY CI 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 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 irate t•the best o y knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in co @Hand At .ent prop` on,of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -de
PLUMBER-GASFITTER NAME LICENSE#``S 2 SIGNATURE
M� MGF.❑ JP`❑ J F❑ LPGI❑ CORPORATION❑#I PARTNERSHIP❑it • LLC❑#
COMPANY NAME `�•f-• \-M; C-91%* `,�,, ADDRESS /.C5 - Dy. I-)1 IPSO CITY COT a STA WO - ZIPO J C TEL! / I `S 1
FAX CELL EMAIL k2i P>nc1GC An/ • i rr)
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