HomeMy WebLinkAboutBLDG-18-000139 =;> MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING tIVORK
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JOBSITE ADDRESS //F//d l_7On OWNERS NAME-CA 5 /!
/ G OWIJER.ADDRESS c -3,0167 �l/vk _ -sk O,1'64i TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL['--
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CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
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APPLIANCES 1 FLOORS-, BSIV1 1 2 3 4 5 6 7 8 9 10 111 12 '13 14 IBOILER _
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BOOSTER I
CONVERSION BURNER I
COOK STOVE i
DIRECT VENT HEATER — ____
DRYER
FIREPLACE . _
FRYOLATOR
FURNACE �' -
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS • _ _
MAKEUP AIR UNIT
OVEN
POOL HEATER
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ROOM/SPACE HEATER
ROOF TOP UNIT . 1 Gf . ZtJ //!/g.TEST 111I UNIT HEATER _
UNVENTED ROOM HEATER I
WATER HEATER _
OTHER I
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IUIGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑' OTHER TYPE INDEMNITY ❑ 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 ❑ AGENT ❑ 11
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 . cure'- _ - est of my knowledge
`— and that all plumbing work and installations performed under the permit issued for this application will be in compli_ . i • . Pertinent provision of the
�' Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
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�} PLUMBER-GASFITTER NAME AJ�'/� 1. / 4✓'n44-''''t LICENSE# SIGNATURE
MP MGF❑ JP ❑ JGF❑ LP I ❑ CORPORATION ❑#F PARTNERSHIP❑# LLC❑#i: I
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COMPANY NAME /`C' tvy ADDRESS 1/ ^1
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CITY 5Gi r.�_.,i✓,.-c./4 STATE/Mit ZIP .2 7 TEL - (V-c;2/Y y-27L.
FAX CELL EMAIL
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