HomeMy WebLinkAboutBLDG-19-004284 ..,-- - wietimbaf20 /805)'\
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY .a. MA DATE..... t5.9 PERMIT# �/—a) 7�
JOBSITE DRESS e OWNER'S NAME 5j f /D
GOWNER ADDRESS m.__. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL, EDUCATIONAL e�w y RESIDENTIAL( ;,
PRINTS ��
CLEARLY NEW: RENOVATION:y, REPLACEMENT: PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER --
BOOSTER
CONVERSION BURNER J
COOK STOVE ...... .
DIRECT VENT HEATER - gr. ,'
DRYER -.�,_ 4
t�..e—
I
FIREPLACE -.,!.
FRYOLATOR
FURNACE ''
GENERATOR
GRILLE J-7 _K.e
INFRARED HEATER
i„,,„_k___11,
LABORATORY COCKS,
MAKEUP AIR UNIT ,,
!_
OVEN I .__..
POOL HEATER i `.
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER_
OTHER
_*,,,,...., ,,,,,,,,,,,__ ,,, INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES x 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 `
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 accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com I' withth al nt provision o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER GASFITTER NAME rIG LICENSE It 1593 SIGNATURE
MP X., MGF JP=F JGF Li LPG! CORPORATION #[ J PARTNERSHIP #' LLC 0#
COMPANY NAME , f ADDRESS; c , I Q3e
CITY STATE Yl� ZIP � TEL, �� �C
FAX j CELLI EMAIL
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