HomeMy WebLinkAboutBLDG-19-002035 ~'` '' MASSACFHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
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JOBSITE ADDRESS 1 5 G 1 a m c l`Z \ OWNERS NAME .l(A`4l CI c.‘C'
GOWNER ADDRESS 5 Am e- 0014M/` ieEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES 1 FLOORS--F
BEM 1 _ 3 1 5 6 9 10 111 12 '13 14 1
BOILER
BOOSTER —�
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CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER i
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER ^� I
I
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN —H
POOL HEATER
ROOM/SPACE HEATER.
ROOF TOP UNIT
TEST
UNIT HEATER � R E e y E D '
UNVENTED ROOM HEATER
WATER HEATER
OTHER 'S I ).:! MI
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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 L�1 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [Ly OTHER TYPE INDEMNITY ❑ BOND ❑
1
• 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 valves this requirement.
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� CHECK ONE ONLY: OWNER ❑ AGENT El. SIGNATURE OF OWNER OR AGENT
"I:: 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 J
� and that all plumbing work and installations performed under the permit issued for this application will be in compliance ith a I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Z kE--J— --e--- 1
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PLUMBER GASFITTER NAME 44-1(61 (A) > \ est-- LICENSE#
52( q SIGNATURE
MP IZMGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION #i PARTNERSHIP❑#r LLC
COMPANY NAME / ❑## I
ADDRESS I- i� ( I,�S O _
CITY S, Vu r tl STATE hAo—
ZIP 02 6 L LI TEL qa ]71t
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