HomeMy WebLinkAboutBLDG-20-000991 _C� .. // MASSACHUSETTS U IFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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VWal CITY f C, /iel MA DATE 22..- 5- PERMIT* &Vb-a.0192977/
JOBSITE ADDRESS /)J Di LC`\`_ 4J OWNERS NAME COI Ile ___
GGWI'IER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO V
•
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 El 9 10 11 12 13 1"
BOILER —1
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER / I
FIREPLACE '
1
FRYOLATOR '
FURNACE
GENERATOR
GRILLE
INFRARED HEATER i
LABORATORY COCKS i
MAKEUP AIR UNIT -
OVEN i J I 22 'ZU19
POOL HEATER
ROOM I SPACE HEATER PART.A.,-____i
ENT
ROOF TOP UNIT M:-f
TEST -..
UNIT HEATER _
UNVENTED ROOM HEATER
WATER HEATER I
OTHER
.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES, NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF OVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BONG) ❑
• 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 ❑
` SIGNATURE OF OWNER OR sii, I hereby certify that all of the details and information I have submitted or entered regarding this application are t nd a urate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co li nce th al� inent provision of the
`` Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE#/0/Cj SIGN4ATURE
MP l_MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION❑ft PARTNERSHIP❑ LLC❑#
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