HomeMy WebLinkAboutG-19-600 �• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
W. CITY /•� kie MA DATE 7'jo"/r PERMIT#6-12b-M-010 066
JOBSITE ADDRESS 3? aJJL.sr (AV OWNER'S NAME /GGCS//
OVJIJER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT �
CLEARLY NEW:0 RENOVATION:2REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 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 • ,�,,,(,lJ
ROOM f SPACE HEATER
ROOF TOP UNIT "--
TEST .. . _ . .... . . . . . _ I ..
UNIT HEATER 2� LU1C C I
UNVENTED ROOM HEATER I 1
WATER HEATER
OTHER
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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 COVE E BY CHECKING THE 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
ti 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- a :t- to the best of my knowledge
} and tshat ull plumbingttsState
work andinInstallations performedptenunder etGenc-ral Issued for this application will be in i� rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBS GASFITTER NAME LICENSE#W, iNiP7 IF SIGNATURE
NIP ye r4GF 0 JP 0 JGF❑ IPGI❑ CORPORATION 0# PARTNERSHIP❑# LLC❑#
COMPANY NAME ,n ADDRESS-TX 1<77
CITY I.V 1 / W-r STATE. Q_ ZIP•4 7L/ 11,1 TEL _a/4-3,42.--.1/..)?)
FAX CELL EMAIL CttsitGRZt'3A,ehrsitl )4414 L. .corti
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