HomeMy WebLinkAboutG-14-529 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CIN ;,-/WI'f'uOkR�h fY02� • MA DATE l / ar [l3 PEI�RMIT#
JOBSITE ADDRESSCa n` t' Lit 111. 4- /a'/ OWNER'S NAME INAadtiPz (oft D
G OWNER ADDRESS lt(r0-'otcryJCf • raII(el WCnry TEL 7)H-S242-dL22_ FAX
TYPE OR / 0232)
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL❑
CLEARLY NEWS RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOI4
APPLIANCES 1 FLOORS—. 8SM 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 •
RF C
.�y� NNAERATOR ) I
-rot
HILL a—rase
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN •
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST I
UNIT HEATER •
UNVENTED ROOM HEATER
W ;: I V E D
NOV 27 2013
BUILDIN RTMENT INSURANCE COVERAGE
I ha ea currea -J10licy 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 POLICY 0 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 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. O ac:NA
PLUMBER-GASFITTER NAME LICENSE# q(p7 SIG
MP❑ MGF❑ JP 0 JGF 0 LPGTg CORPORATION❑# PARTNERSHIP 0# Zip-
CITY LLC❑#
COMPANYNAME r tr�iGttiS ADDRESS ) 3 7yaw� o(1
14yctAxt?b STATE f43 ZIP 02,100 J TEL(.03• 'n c al'?!p
FAX 501`M -sits 6I CELL EMAIL
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