HomeMy WebLinkAboutBLDG-17-006560 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
F CITY yA /'r1 oaTMA DATE thY/72 PERMIT it ✓%406" OQrpca6
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JOBSITEADDRESS /(Yard,A,'74 OWNER'S NAME J'e /l 5,•• s1/ Se ygih
GOWNER ADDRESS 0 7y four/-4 5T iliZsc-15r5'x/ TEL rat. 3iY -o6 X"-??
TYPE OF. OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION: $ REPLACEMENT:❑ PLANS SUBMI I I LU: YES❑ NO❑
APPLIANCES 1 FLOORS-' BEM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER -
COOK STOVE a
DIRECT VENT HEATER
DRYER
FIREPLACE /
FRYOLATOR _..
FURNACE a EF Y n i V 1•
GENERATORGRILLE
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INFRARED HEATER II(N 14 1 I
LABORATORY COCKS
MAKEUP AIR UNIT r 'iiiDil�ut
OVEN B -- ---
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 equivalent which meets the requirements of MGL Ch.142 YES 0 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TEE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 0 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 true and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
LEIMassachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ram,eL Apr-c_ LICENSE# /3 t 7. SIGNATURE
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