HomeMy WebLinkAboutBLDG-17-005763 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I
CITY k DATE PER T# 'c19 G
JOBSITE ADDRESS_?6 %,r O.r 11,41i OWNER'S NAME C11/
• OWNER ADDRESS (5 TEL FAY
TYPE OR OCCUPANCY TYPE COMMERCIAL
PRINT ❑ EDUCATIONAL 0 RESIDEIJTIAL
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMI I I EU:YES 0 NO 0
APPLIANCES 7 FLOORS-. ESM 1 2 2 4 5 6 7 J s 9 10 11 12 13 14
BOILER -�
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER
DRYER f.
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR l
GRILLE (9li f `)
INFRARED HEATER - r-
LABORATORY COCKS j
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM SPACE HEATER
ROOF TOP UNIT
TEST -
UNIT HEATER 1
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'NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0 �I
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❑
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 acc to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com Ga ce wi P 'n provision of the
Massachusetts State Plumbing Code and Chapter
42 of the General Laws.
PLUMBER-GASFITTER NAME /la/m,L Af 44 LICENSE# SIGMA
MP❑ MGF❑ JP JGF❑ LPGI❑ CORP RATION❑# PARTNERSHIP # LLC❑#
COMPANY NAME ADDRESS
CITYI Q!-Q D STATE ZIP TE
FAX CELL 57?,,frIl EMAIL
242
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