HomeMy WebLinkAboutBLDG-18-006883 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS /G 9 l MH4-e £hc OWNER'S NAME na"1-'41 r `)'"'vier
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL ❑ RESIDENTIAL®—
PRINT
CLEARLY NEW:S" RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-, BEM 1 2 3 4 5 6 7 ?, 5 10 11 12 13 14
BOILER
BOOSTER • I
CONVERSION BURNER J
COOK STOVE 7—
DIRECT
DIRECT VENT HEATER •
DRYER /
FIREPLACE /
FRYOLATOR
FURNACE
GENERATOR .
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN • r
POOL HEATER •
ROOM I SPACE HEATER St41 0 g 24
ROOF TOP UNIT 4 –
TEST . ... . . . . . ...._ ...... . . G
UNIT HEATER •
LII'4VENTED ROOM HEATER
WATER HEATER
, OTHER
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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 E?,,I S ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE, BY CHECKING THE APPP.OPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IV' 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,arid that my signature on this permit application waives this requirement.
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 tru id accurate tott of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in c lie ce with all P i rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,
PLUMBER-GASFITTER hNAME1( Ja H el O vA. LICENSE tl 3_3 3 0 5 SIGNATURE
MP ❑ MGF 0 JP VJGF❑ LL�PGIA❑ CORPORATION❑41 PARTNERSHIP 0# LLC 0#
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CITY T/G tc.�( STATE✓ " ZIP Oa- ( `/ f TELCOT'LI102--
FAX CELL EMAIL 6 a .Ira Ho�Je S IQ GA Q;/
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(-7L- 74911 /W/4