HomeMy WebLinkAboutBLDG-19-002181 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
� � CITY S` keit/00X AAA DATE �D-�!/0 PERMIT k� t�f� IY-GQ�IJSI
JOBSITE ADDRESS ?/eenhid SaA ey Ain OWNER'S NAME/34144/,lnne any
GGW'1ERADDRESS 5i' it TEL 7f-49 -5( FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATION.AL 0 RESIDENTIAL,'
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT)4 PLANS SUBMITTED: YES 0 IJ
APPLIANCES 1 FLOORS- 8811.4 1 2 3 4 5 6 7 8 9 10 11 12 13 1e 1
BOILER
BOOSTER ----`
CONVERSION BURNER • RS L
COOK STOVE A ' _-
DIRECT VENT HEATER O ,r
� f
DRYER L .1 //r r r 1
FIREPLACE BUILD, E
FP.YOLATOR °r " Rfiu{-J_
FURNACE 1--- t
GENERATOR `�_
GRILLE —
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT ' •
OVEN
POOL HEATER • .
ROOWISPACE HEATER
ROOF TOP UNIT
TEST . ---- -- •• -•-
UNIT HEATER
INVENTED 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
IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 4( 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
3CHECK ONE ONLY: OWNER 0 AGENT 0
. SIGNATURE OF OWNER OR AGENT
`it: 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 knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with al Pertinent p ' of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /`'`c_/ln
PLUMBER-GASFITTER NAME LICENSE 0caw_ SIGNATURE
MP❑ MGF 0 JP 0 JG$D LPGI 0 CORPORATION❑4 PARTNERSHIP 0# LLC 0#
COMPANY NAME `24e004/1{�/file*Acte!. S ADDRESS 77
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CITY k'IjT Oent1M STATE fl66 ZIP 0470 TELS )F ;46 .315?-'
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