HomeMy WebLinkAboutbldg-19-005935 -- IVIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`�:ks-__=.,�� COT`( 1/�V'�++avf f�, MA DATE l �8j/9' PERMIT
JOBSITE ADDRESS 6.5 Si',errar 1✓y OWNER'S NAME A- Oeargiq' pe/f•, el-r;gdts
GOWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL,
PRINT
CLEARLY
NEW:❑ RENOVATION: g REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑
APPLIANCES-1 FLOORS— BCM 1 2 3 4 5 6 7
8 9 10 'I'I 2 1� .13 14
BOILER —1
BOOSTER 1 - _�
CONVERSION BURNER,
COOK STOVE I
DIRECT VENT HEATER
DRYER —
i
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE i
INFRARED HEATER
LABORATORY COCKS j�3; a i
MAKEUP AIR UNIT _ ..JV (J
OVEN 1
J
POOL HEATER r' I
ROOM/SPACE HEATER I ,.
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES-'�Z] NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY ❑ BOND ❑
OWNERS 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.
1
-, CHECK ONE ONLY: OWNER ❑ AGENT ❑ I
SIGNATURE OF OWNER OR AGENT i
�••• 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 Stark), terlistawskJ LICENSE# 3366 4/ SIGNATURE
MP ❑ MGF❑ JP IX JGF❑ LPGI ❑ CORPORATION❑#F PARTNERSHIP❑#t LLC❑#i
COMPANY NAME •-fY FIsi ,4;y -i, Mile, ADDRESS Pi liex /-1 2-
CITY IVOs 1- avaai, STATE 4i4- ZIP °a-469 TEL
FAX CELL 77 V`X;----o-• +s EMAIL SL`.�p/vsnbii� t,'mites, 4-7h1
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