HomeMy WebLinkAboutBldg-17-004233 •i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS I 5 , t+2wv OWNER'S NAME � �
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OWNER ADDRESS TE= FAX I 1
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TYPE OR OCCUPANCY TYPE COMMERCIAL . EDUCATIONAL: ' RESIDENTIAL
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CLEARLY NEW:I , RENOVATION •i_ • REPLACEMENT:P . PLANS SUBMITTED: YES El N0
APPLIANCES 1 FLOORS--k BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _.
BOOSTER �� 4�
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CONVERSION BURNER ` S ' `� ,
COOK STOVE , - i _
DIRECT VENT HEATER , •
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DRYER _. , _ � # .,_...��M ;:_.. ,��
FIREPLACE t °� ,.. . ..S.
FRYOLATOR _ P
FURNACE t..,._ ..� .,;m....,..., . .;A.,5 .P ,„ .L .1 .--
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GENERATOR , .�.> .� .::_, .�.�
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GRILLE ;..._ ,L— a, _ - '----,1 - , w ««�
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INFRARED HEATER �..`,.—...the....a..,--,... -. ...4--i--T --k ,t y
LABORATORY COCKS
MAKEUP AIR UNIT _.
OVEN .t.
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POOL HEATER i
ROOM/SPACE HEATER .; _ - _
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ROOF TOP UNIT .�-. , �:.; ,
TEST i s
UNIT HEATER .. -s_-s ,,,.._. .. ...i i .:r. :.. 3.,,...,... ,._. : r ... {
UNVENTED ROOM HEATER
WATER HEATER
OTHER.
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INSURANCE COVERAGE _
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO �..,.
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE SOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY T BOND I
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverge required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY• OWNER 11,j AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application Ore a accu; to= : • of • k edge
and that all plumbing work and installations performed under the permit issued for this application will be in- wi -:I Pe ' - p . •S;__
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER GASFITTER NAME I C-t et 5 t-z.vi1 e.� R- 51,1 c-vt1 4 LICENSE#E 1076 SIGNA URE
MP n MGF E JP „l JGF I LPG! CORPORATION I N6 #I PARTNERSHIP= ##I LLC #I
COMPANY NAME:, rrli's P r t uvt 10 r t
ADDRESS wxty-
CITY I kitSTATE ., jZIP; ZCe� TEL g a[�l 7 l l t. �>
FAX CELL; /EMAIL' S/1 OCO c 1: ems/(lox-, ► 7' :_.
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