HomeMy WebLinkAboutG-19-6828 .2‘.--..,
— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
V 6` CITY p ix fii nu MA DATE PERMIT#/9 ft-0 Ng
JOESITE ADDRESS C Sym I+ke. S 1`�c.,; A/i_ �Z OWNERS NAMEj7 Al` TAZ (C K Co F{,3,,_
GOWNER ADDRESS t ` TEL ScZ 76' Y`8b FAX
O TYPE OR �,
PE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL I�/
PRINT
CLEA_RLY NEW:V RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-I. FLOORS—+ BSM 1 2 3 4 5 6 7
8 9 10 11 2 1 '13 1
BOILER —1
BOOSTER
CONVERSION BURNER, i
COOK STOVE
DIRECT VENT HEATER
DRYER
I - _ 1
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE '
INFRARED HEATER I
LABORATORY COCKS I
MAKEUP AIR UNIT t:7:;‘
OVENl iiJ
POOL HEATER A IROOM(SPACE HEATER �OU ) tt02,1rIlriiV".-
i:; L u i�,f i
ROOF TOP UNIT
TEST Y
UNIT HEATER '
INVENTED ROOM HEATER _
WATER HEATER i
OTHER 50o L/7 7iji✓/L —1
U G- Gets L;vie 1 I I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of!IGL.Ch.142 YES 5t NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY if. - OTHER TYPE INDEMNITY ❑ BOND ❑
Il
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 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 I
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME 13 g SA 4) 5'e'' `- 6-t Fax/ LICENSE#12SS'S ' 4 SIGNATURE
MP MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# I
COMPANY NAME C '��e Ca A a(( ('en(Pic (A6 ADDRESS P,U 3n se1 r q3 0 FC I
CITY/ icc0 J it t Q C-7 C J 11,z1 STATE 4 t ZIP Q 7 6 5'7 TELS Ce tf 8 7 v Z O I. I
FAX CELL SO TI j E.6 —80e( EMAIL b r 5-to(c.nCsl-e e' ktitpJ\rah,
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