HomeMy WebLinkAboutG-19-1796 ...LLQ
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK +,
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JOBSITEADDRESS65 v*4lib()g CC" OWNER'S NAME 'O ` e Fit
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OWNER ADDRESS � * TEL FM
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Er
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:Er PLANS SUBMITTED: YES 0 NO❑
APPLIANCES-I FLOORS-. ssM 1 2 3 4 5 6 7 s 9 10 11 12 13 14
BOILER ---
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE •
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT k h C E I lif U
OVEN
POOL HEATER •
ROOM I SPACE HEATER p 25 20 8
ROOF TOP UNIT _ c41
TEST . ' • ti f9i��� _
ARl AI'J1 t_.
UNITHEATER
1II1VENTED 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 EELOW
LIABILITY INSURANCE POLICY 1 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 ❑ 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 accur to the best of my knowledge
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and that all plumbing work and Installations performed under the permit Issued for this application will be in c pliance with alh rtinent provision of the
'v} Massachusetts State Plumbing Code and Chapter 142 of the General Lamq
PLUMBER-GASFITTER NAME 9 (O LICENSE# SIGNATURE
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CITY MI 'c4Wr [Mfits STATE .L{g1 ZIP o `,r'•�6' TEL1 O 737 og ii
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