HomeMy WebLinkAboutBLDG-19-001595 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITYVS+S' 1AntA0vM MA DATE q\q!\\ZS PERMIT# hi-db-8-4117/6-9C
JOBSITE ADDRESS 7--4 h t Ryr. 1psdut., OWNER'S NAME h is 1/4\�tnr
OWNER ADDRESS TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NE.AtikalRENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE R h C E.. 1 V I ti
GENERATOR
GRILLESCf P7'.
INFRARED HEATER Y �u�u
LABORATORY COCKS
MAKEUP AIR UNIT tit it kir' p
OVEN
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST . .
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalentwhich 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 BELOW
LIABIUTY INSURANCE POLIet-5 OTHER TYPE INDEMNITY 0 BOND ❑
• 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
T` I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a r�he best of my knowledge
and that all plumbing work and Installations performed under ttheteer Issued for this application will ba � -M provision of the
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME UCENSE#%Y"j IZ SIGNATURE •
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COMPANY NAME`INAV 5\ C. Q s 1 ADDRESS T�O ppX 9O CITY e...oxu STATEu/\ 1 . ZIP 02(035' TEL-1—?4--'' e-nrof
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