HomeMy WebLinkAboutBLDG-19-001983 /ia
IL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOESITE,ADDRE•SS ga cleft lit.A-Jb (J..?Pf OWNER'S NAME (Su -it-
GOWNER ADDRESS TEL SCE"XG-tpc- FAX
TYPE OROCCUPANCY TYPE COMMERCIAL EDUCATIONAL �r_
PRINT OM�4ERCIA ❑ DU�A'i IONAL ❑ F�SIDENTIAL�}'
CLEARLYNEW:❑ RENOVATION:ly REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑ !
APPLIANCES 1 FLOORS-4 BSIvi 1 2 3 1 il 5 6 7 9 10 11 12 13 14 1
BOILER ______I
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _______i
DRYER
FIREPLACE l �-
FRYOLATOR
FURNACE I
GENERATOR. I
GRILLE
INFRARED HEATER I
LABORATORY COCKS •
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MAKEUP AIR UNIT i
OVEN i
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST _ .
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UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I
S OTHER
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INSURANCE COVERAGE
• I have a current liability insurance policy or its substantial equivalent which meets the requirements of 1UIGL.Ch.142 YES ® NO ❑
v I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �1
�, LIABILITY INSURANCE POLICY yr OTHER TYPE INDEMNITY ❑ BOND ❑
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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.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑ I
SIGNATURE OF OWNER OR AGENT
"1-, 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
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` and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i
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PLUMBER-GASFITTER NAME LICENSE# xutei SIGNATURE
MP ❑ MGF n JP JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME ma- e,,,,,v1.1.4 ADDRESS
���("^P--oGox �3 C' {� n
CITY w`f,Sl6 �S*tj6. STATE M,� ZIP l.'vVOC TEL k- i3I'"'5S(?1
FAX CELL EMAIL M CL t L_Iiit 1,M •(d"
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