HomeMy WebLinkAboutG-13-306 -LL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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aH�' - CITY C J( ineiMA DATE /� a� PERMIT# L749— 3i
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JOBSITE ADDRESS yre 97 f'✓LGf/'/) .4_00I VR'S E OM 7544S ."7/rtfio�
GOWNER ADDRESS e 1 I -s 13f�c IITEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL g
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CLEARLY NEW:O RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS- BSM 1 2 3 4 _ 5 6 7 B 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE �} (��{ 7y -ti
GENERATOR fif E lrl E F U L5
' GRILLE n
INFRARED HEATER IJ (1C" R 1 9(112
LABORATORY COCKS
MAKEUP AIR UNIT r. 0 i , ,A
OVEN r
POOL HEATER
ROOM/SPACE H EATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER )C
OTHER
INSURANCE COVERAGE 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Il; NO 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: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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# ?j/911.; SIGNATURE
MP 0 MGF 0 JPJGF 0 LPG!❑/� 1CORPORATION 0# PARTNERSHIP 0# LC #
COMPANY NAME 1 ")
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CITY W ' 0l-►'-u./4 STATE ZIP 026 t7 TEL 5v 3 6d 13 g -I
FAX CELL EMAIL
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