HomeMy WebLinkAboutG-14-552 lca MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
t-AV CITY Sookh 1Qnabli MA DATE Ia—?—I3 PERMIT# v/y-5Y2
JOBSITE ADDRESS 10 Poo. Seasons Ave. OWNER'S NAME j-)-ohjood1
GOWNER ADDRESS - TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT �/
CLEARLY NEW:,I� RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 N
APPLIANCES 7 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
ROOF TOP UNIT
TEST
UNIT HEATER
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BUlLpi RTMENT
ev-. INSURANCE COVERAGE
I hive a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESAINO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:lam 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 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 all ertinent provision of the
Massachusetts State Plumbing CodeandChapter 142 of the General Laws. :ALL
)L E
PLUMBER-GASFITTER NAME 6 j� -FOE Im6 LICENSE# 39 9 a.- �/ SIGNATURE
MP 0 MGF 0 JP❑p JGF GI 0 CORPORATION 0# PARTNERSHIP❑# -T LLC 0#
COMPANY NAME gig I I y NDI mts ADDRESS I , I elft I rcl l
CITY Sandwt*Lb I STATE IAIE} ZIP o -563 TEL 77Y--g) 69-9797,
FAX • CELL EMAIL