HomeMy WebLinkAboutG-13-720 •'�.�-__' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS g3 CL/1 I I U St OWNER'S NAME 94 VI A, tir i'k�QJ V'
G OWNER ADDRESS Z3 kit IIUU) .S7' TEL FAX
TYPE OR OCCUPANCY E COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER J
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR 22 H) IK C
FURNACE n
GENERATOR lilt
GRILLE JAN 3 1 2013
INFRARED HEATER ^' LOINCD.fT
LABORATORY COCKS By I
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST •
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
(J11,-Ly N 4 4- 1 _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent ich meets the requirements of MGL.Ch.142 YES 0 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND ❑
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 ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application area �f d ace - to the best my knowledge ..
and that all plumbing work and installations performed under the permit issued for this application will be in c�pli; ce a Pertinent pi ision if the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBS ASFITTER NAME LICENSE I 706/ SIGN r URE
MP ' MGF❑ JP 0 JGF❑ LPGI 0 CORPORATION❑it PAR ,NERSHIP❑# LLC # �/Z3
COMPANY NAME .I ' 41r f O '� /N 1' ADDRESS /5-3l J t't . i,V Com! t•-'1 f
CITY inV✓f (/1/9-•2� STATE*k ZIP ��ZIP Li/ TEL 7 / �? 4� I)
FAX - CELL EMAIL
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