HomeMy WebLinkAboutG-13-802 /4; 30 - I/:o°
rMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-7477CUY tWIAinA tt. . ...:_I MA DATE[ -I 1L3..� PERMIT# b/J —7002
JOBSITE ADDRESSr31 ' !4 eILI( til ek. f OWNER'S NAMEc)_
OWNERADDRESS L: JTni, _.. IFAXL
TYPE OR OCCUPANCY TYPE COMMERCIAL( EDUCATIONAL I . RESIDENTIAL,
PRINT
CLEARLY NEW:0 RENOVATION:'.,^) REPLACEMENT:5 PLANS SUBMITTED: YES 11 N
APPLIANCES 7 FLOORS-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER t_.,
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
OTHER
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YEStri NO 5
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY7 OTHER TYPE INDEMNITY L__2! BOND 1
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 pemdt application waives this requirement.
CHECK ONE ONLY: OWNER D AGENT C
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and manna lon I have submitted or entered regarding this application are •. _to the best of my knowledge
and that all plumbing work and installations performed under the penult issued for this application will be in lance I ant of the
Massachusetts State Plumbing Code and Chapter 142 or the General Laws. 0,,
PLUMBER-GASFITTER NAME ((JJQgtot t/7 cyj/2t) 1 LICENSE# l07o 6 I SIGM TURE
MP JI MGF 0 P�,,] JGF I ] LPGI[-_-] CORPORATION f—#�w _I PARTNERSHIP=# LLC fl#
COMPANY ADDRESS1i 39
CITYI:�il_YL 1 _ .:_ _._ STATE L_, i 4!- �,rtiirrae v4� 7�Ji/`1_ ...... 1
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FAX L < _:_________ CELL = !EMAIL I
11AR 0 5 2013
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