HomeMy WebLinkAboutBLDG-18-003735 ,_I I'`''' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
6 A CIT( 3 !'v►'t-ls�J MA DATE I 02Co /17 PERMIT#A-4—11�-®G���'.�lJ
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JOBSITE ADDRESS 6u ; / i A Rdt OWNER'S NAME aa""""i'e OU P
GOWNER ADDRESS g S 0 u Sr_ &r411;1 LN►A D L o 3 3 FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ��
PRINT ❑ f,�SIDEIVTIAL�
CLEARLY NEW:tt RENOVATION: ❑ REPLACEMENT:
❑ PLANS SUBMITTED: YES❑ NO 0
APPLIANCES 1 FLOORS-h B8M 1 2 3 4 5 6 7 8 9 10 11 12 13
BOILER 14 1
BOOSTER _______I
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER, — _
FIREPLACE i
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER -_
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN -
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST _. -
UNIT HEATER . �— . ._
UNVENTED ROOM HEATER
WATER HEATER I
OTHER -____I
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 BOX BELOW
LIABILITY INSURANCE POLICY VI OTHER TYPE INDEMNITY ❑ BOND ❑
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
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Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
•-, SIGNATURE OF OWNER OR AGENT J
\� 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 corns nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �e , �/ 1
PLUMBER-GASFITTER NAME LICENSE#1:2` Wq SIGNATURE
MP ❑ MGF❑ `JP ❑ JGF❑ LPG' ❑ CORPORATION❑it PARTNERSHIP❑#r LLC❑###
COMPANY NAME _Look, e- T/12 Pl U M -Dr ADDRESS Y 3 S-,
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CITY J/ po r T STATE /•�-A ZIP 0 )4 3 q TEL 3q-e 3 83 1
FAX 67)rSLL'.___3 C 8 3 a 8 'S EMAIL
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