HomeMy WebLinkAboutG-13-1024 ,.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING
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JOBSITEADORE SS..9 41I6a> -Q__- w TOWNER'SNAME ISSIa-+�4...L1ii4IECt1Cj K. „.. . ..T
GOWNER ADDRESS y T�1_V., . . _.d...aF L ,.-.... -
TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL j RESIDENTIAL&
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CLEARLY NEW:[j RENOVATION:D REPLACEMENT:[!} PLANS SUBMITTED: YES IT. NO1 j
APPLIANCES 7 FLOORS-, BSN 1 2 3 4 5 6 7 6 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/SPACE HEATER
ROOF TOP UNiT
TEST
UNIT HEATER _ _ _ .. __.-
UNVENTED ROOM HEATER
WATER HEATER Ark
OTHER I
INSURANCE COVERAGE -
I have a current liability Insurance policy or b substantial equivalent which meets the requirements of MGL Ch.142 YES (e'1 NO n
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY M. OTHER TYPE INDEMNITY j 1 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 fl AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby notify lu bi aB of the details and Information I have submitted he entered this
t pp this application�ry 9 / best d my of th knowledge
d that all plumbing soak and Codeatiperformedp14under ofthetGenpermitl Issued for tWs application v49 ba' d the
Massachusetts State Plumbing Code and Chapter 142 tithe General Laws.
PLUMBER-GASFITTER NAME (hr./we/Lev �l�l� I UCENSE# /070S- SIGNATURE
MP'32 MGF Li JP El JGF[] LPGI L,._ ... CORPORATION E#[ J PARTNERSHIP 0,# I LLC nil
COMPANY NAME.111/4_S(J.Wt&b1t'ff'i __IADDRESS[pA 3( 3y
CITY Labe_ ail.118t7?1J_l� _i STATE 1./.1.M, LP[o24 ..�._.1TELL p _7.78--`-9f1, --,�Hit Is 0 L.
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