HomeMy WebLinkAboutBLDG-19-006229 FOArSi—
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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\\- A. DATES .O& /P'—3 PERMIT#,
JOBSITE ADDRESS NTIVGi/Vef J tZ OWNER'S NAME: /9L 77S/ 407
GOWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Pi-'''''..-
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0
APPLIANCES? FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR ,
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT i MAY 0 K
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
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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[p NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY/ OTHER TYPE INDEMNITY 0 BOND ❑
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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are. e and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this applicat�be I.compliance with all Pertinent
provision of the Massachusetts Sta lambing Cod Chapter 142 of the General Laws. / /
PLUMBER/GASFITTERNAM e1iis CJ) J LICENSE#_____ '-TORE
COMPANY NAME: ADDRESS: `_' r//S77
CITY:G4 7�ZJ(C.)10L" STATE? ZIP:/12_147 FAX:
TEL: CELL.9c 7/02../ EMAIL: 5-
MASTER❑ JOURNEYMAN❑ LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
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