HomeMy WebLinkAboutBLDG-18--2091 - - -
MASSACH0SETTS UNIFORM APPLICATION FOR A PERMIT TQPERFORM GAS FITTING WORK
CITY ~^/��� �A DATE' \ JPERN|T# ����w
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JOBG|TEADDRESG| a"A OVVNER'SNAME
OWNER ADDRESS
TYPE OR OCCUPANCYTYPE COMMERCIAL'—' EDUCATIONAL RES0ENT|�L��
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PRINT
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CLEARLY
NEVV�7~ RENOVATION:: REPLACEMENT: PLANS PLANSSUBM|TTED. YES| NO��
APPLIANCES 1 FLOORS- BGM 1 2 3 4 5 h 7 8 O 10 11 12 13 14
BOILER --'-- ,--- ` '--- � ---�' ' --,---
BOOSTER
CONVERSION BURNER F
COOK STOVE nuff, "Numn3off -
DIRECT VENT HEATER "WMWWWWWWWOMMWOMMOMONOWNW-1;
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
,mm
POOL HEATER
ROOF TOP UNIT
ROOM/SPACE HEATER
am-'.,-X
TEST
UNIT HEATER
UNVENTED ROOM HEATER 'j
WATER HEATER
OTHER
INSURANCE COVERAGE
|have m current liability insurance policy or its substantial equivalent which meets ft requirements oyMGL Ch.142 YES N0 �~u
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY tp� OTHER TYPE INDEMNITY '-- BOND [-?
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OWNER'S INSURANCE WAIVER:|am aware that the licensee does not have the insurance coverage vequiredbv Chapter 142nfthe
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: UWNERF-/ AQENT '_-�
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SIGNATURE OF OWNER ORAGENT
|hereby certify that all v,the details and information/have submitted o,entered regardingthis application are true and accurate m the best o,mvknowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co iance with 11 P rti nt provision of the
Massachusetts State Plumbing Code and Chapter 14uvv the General Laws.
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PLUMBER'GASF|TTERNANE U r����SENSE# � ,' ^a/uNATURE
MP �u~ �GF[-� JP JGFF-� LPG|[-1 CORPORATION ---�PARTNER8H|P--#| �LL�F-�
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COMPANY NAME:
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C|TY GTATE� y�� ��|P TEL��
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