HomeMy WebLinkAboutG-14-487 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS:41 PIG" ( /1S-7-- 2? OWNER'S NAME:
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OWNER ADDRESS: Cl/c, Qs(Y-el) ?cmbet-liTEL' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:Er REPLACEMENT:❑ PLANS SUBMITTED: YESJO❑
APPLIANCES1 FLOOR—, I Bsmt 1 1 1 2 1 3 1 4 5 6 1 7 1 8 9 1 10 11 1 12 1 13 1 14
BOILER I I I I I I I
BOOSTER I I I I I I I
CONVERSION BURNER I
COOK STOVE I I I
DIRECT VENT HEATER
DRYER I I I I ,
FIREPLACE I I I I I I I
FRYOLATOR
FURNACE I y I I I I I I
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GENERATOR
GRILLE I I
INFRARED HEATER I I I I I
LABORATORY COCK I I I I I I
MAKEUP AIR UNIT I I
OVEN
POOL HEATER I I 1 I •
ROOM/SPACE HEATERI I I
I ROOF TOP UNIT I I I
TEST l I
UNIT HEATER I l
UNVENTED ROOM HEATER I I
WATER HEATER
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INSURANCE COVERAGE 7' -Ce
I have a current liability insurance policy or its substantial equivalent which meets the requirements of L C142 YES &NC❑
If you have checked YES please indicate the type of coverage by checking the appropriate box below. moi' `a
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 Bs”•49 �
OWNER'S INSURANCE WAVER I am aware that the licensee does not have the insurance coverage required by Chapte •42 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
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 Per5nent
provision of the Massachusetts State Plumbiii g Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTE�RnNAME f vJ( tC{�C�6J'r�r�///� LICENSE#/�G�/ / SIGNATURE�
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