HomeMy WebLinkAboutBLDG-19-002724 S MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS—n 2.0 Yla OWNERS NAM?- - IOW r7S
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL-IS:,
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CLEARLY NEW R RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
APPLIANCES-1 FLOORS BSM 1 2 3 4 s s 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 COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER • I '
ROOM I SPACE HEATERr.
ROOF TOP UNIT hUV L b 2018
TEST
UNIT HEATER 3uiLD NGVD=FARinncp
(INVENTED ROOM HEATER LP. __
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 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY - OTHER TYPE INDEMNITY ❑ 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 tills requirement.
CHECK ONE ONLY: OWNER ❑ AGENT 0
J 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- and . - - .the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be'n c. peril provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-I3ASFITTER NAME LICENSE#1512 SIGNATURE
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