HomeMy WebLinkAboutBLDG-17-006478,\ 7_—:'" ,.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
To• T �"�- MA DATE / j2 PERMIT 4 P7.--,d r-17-600q '
e.=� s CITY L1'w�c�
JOBSITE ADDRESS ‘e-,S 's%. r eG..- \5���•.-- OWNERS NAME -3e5 e f L 'J c.rct-so
GOWNER.ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0-----
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CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: IV PLANS SUBMITTED: YES ❑ NO LE
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APPLIANCES 1. FLOORS BSM 1 2 3 1 5 6 7 ° 9 10 11 12 '13 1'
BOILER _______I
BOOSTER —I
CONVERSION BURNER _ '
COOK STOVE --'
DIRECT VENT HEATER
DRYER — I
i
FIREPLACE '
FRYOLATOR
FURNACE
GENERATOR I I
GRILLE
INFRARED HEATER __/
- i
LABDRATOR( COCKS •
MAKEUP AIR UNIT
OVEN JIM . 0
POOL HEATER
ROOM/SPACE HEATER CA L U 6 c‘,
ROOF TOP UNIT
TEST -
UNIT HEATER
INVENTED ROOM HEATER / I
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES Nd ❑
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE Y CHECKING THE APPROPRIATE BOX BELOW I
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 accu to to the best of my knowledge
`s- and that all plumbing work and installations performed under the permit issued for this application will be in compliance all Pertinent provisio le
�' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
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PLUMBER-GASFITTER NAME 6 C e�,_ _ S L e,G_ LICENSE#Z-02-/7' SIGNATURE
MP E MGF n JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LC❑#
COMPANY NAME ] ADDRESS ?-U �'tc-cc/L 5 l GJl4 p d,
CITY / �f w Cc- STATED 74 ZIP G 2-i L/j— TEL 22 GC//- /G
FAX CELL EMAIL
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