HomeMy WebLinkAbout2022 Gas Permit i v E t :SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
e-_.6 CITY �+a ,Y�(1v1.v4,l, h�iA DATE cam- 3
1 2022 PERMIT#
JOBSI'E ADDRESS Imo- J�hic,�ry� 41 OWNERS NAME
,:uTL N DEPA�rAEALT
IADDP,ESS J il),-i' rvo TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL T1*-----
CLEARLYNEW:❑ RENOVATION: REPLACEMEN f: ❑
PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-I BEM 1 9
BOILER 3 A 5 F o 9 10 I'i 12 13 14
BOOSTER
COPJVERSI00 BURNER
i \ !
I
COOK STOVE,.
DIRECT VENT FIEATER
DRYER T
FIREPLACE j
FRYOLATOR _
FURNACE _____________I
GENERATOR
GRILLE 1
INFRARED HEATER
LABORATORY COCKS _ ---____H
MAKEUP AIR UNIT
OVEN —�
POOL HEATER •
L____1
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
NIT HEATER -- - ---
INVENTED ROOM HEATER •
WATER HEATER _
OTHER
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of PUIGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND
El
• 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.
SIGNATURE OF OWNER OP,AGENT CHECK ONE ONLY: OWNER ❑ AGENT El
` : 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.
LU
PLUMBER-GASFITTER NAME LICENSE# 3�6_, fr. SIGNATURE'
MP ❑ MGF❑ JP T IGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# Lc
COMPANY NAME g-e-1 r4-. _ ADDRESS / 1 t r P fa-
CITY o i c ,‘„ STATE A ZIP TEL
4.tie-V TEL C5Z, ASS 3
FAX CELL $ EMAIL