HomeMy WebLinkAboutBLDG-19-003500 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
%vac CITY �1�r MA DATE 121)0 1 W PERMIT#4_D6/'f-,ct73, 00
JOBSITE ADDRESS SL/o I 1- 4-L, WoOd OWNER'S NAME KT S .
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO'
APPLIANCES Z FLOORS-' SEM 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 a j b C £ I Y e-
GRILLEr1O
INFRARED HEATER A (_C 70 2 19
LABORATORY COCKS M 11
MAKEUP AIR UNIT
�7 l;r ecnrT
OVEN BU14Lnv o
POOL HEATER •
ROOM/SPACE 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 [X] NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW •
LIABILITY INSURANCE POLICY N • 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 ❑ 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 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 at Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITIER NAME ft." C3tSo.. LICENSE# Z6)02- SI" SIGNATURE
MP❑ MGF D JP ID JGF 0 LPGI 0 CORPORATION❑41 PARTNERSHIP❑# LLC 0#
COMPANY NAME l-3 (1\Cor. ,e4 ADDRESS 2:a SL..qa,. d /n
CITY (17 Mao STATE MA- ZIP 02360 TEL )Y/ -te) Wet
FAX CELL EMAIL • P�
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