HomeMy WebLinkAboutG-14-655 �* 5• h MASSACHUSETTS�/ UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESS cO gni ez7' Ar Gylr ' >1 OWNER'S NAME arrc,kiry -if;'2 ✓4c�r
GOWNER ADDRESS SC? 4/rrZ Y 7>' Rd TEL YS/ — fd (o FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL W
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CLEARLY NEW:❑ RENOVATION:[13, REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOW
APPLIANCES I. 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 L
GENERATOR
GRILLE
• INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER 1— f rn-f") 1
ROOF TOP UNIT R E C f. =--
TEST X11
UNIT HEATER 9n1d: H.
UNVENTED ROOM HEATER JAN '
WATER HEATER 1 41913(r i-T 4Y r
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ANO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CQVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IA` 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 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 co�m^�ppllii nnccejewith all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � `-t
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP 0 MGF 0 JP JGF 0 LPGI 0 CORPORATION 0# r7 PARTNERSHIP 0# LLC 0#
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COMPANY NAME '/1. (f ffCGt ADDRESS 2/ 5'r5 rer O c
CITY w• LCIe "ril STATE lin ZIP OD ci G TEL "i7 ,) eon. Yeo
FAX CELL /7g/ a41'i4190 EMAIL
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