HomeMy WebLinkAboutBLDG-19-003049 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY \I Arrti\O t h L2A ` MA DATE 1)I PERMIT# PX46--/9--an ,7Orq
JOBSITEADDRESS 7Z \�XAnvlC 1g{7OWNER'S NAME hoc'SAC-1..
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL.
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CLEARLY NEWS, RENOVATION: 0 REPLACEMENT: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
ROOM I SPACE HEATER R E C E , V��
ROOF TOP UNIT
TEST r _ —
UNIT HEATER NOV 16
:018
UNVENTED ROOM HEATER
WATER HEATER L -
OTHER By .r. .. ;- ae.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YE$. NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLIO. 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
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 accurst-{. bbest of my knowledge
3- and that all plumbing work and Installations performed under the permit Issued for this application will be I comp!'- th qP,-,0�f;. 'vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.LLI r {t//✓'
PLUMBER-GASFITTERNAME LICENSE# 11St2_ SIGNATURE
MP� MGF 0 `1 JP 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# LLC❑#
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CITY 60\ i,.l�1. STATIMCK-- ZIP 6a�S TELA [`f'nt-_`oaL
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