HomeMy WebLinkAboutBLDG-17-006484 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY y/tCr o MA DATE 6—(d -c PERMIT �1� "� /
JOBSITE ADDRESS a a c-`c, S-e 2 Ln-Ne OWNER'S NAME 514-,0e,4/A T11J N D
OWNER.ADDRESS a-a C,rc.i S e LAr e- TE( ya IS FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO ❑
APPLIANCES T FLOORS- KM 1 2 3 4 5 6 7 5 9 10 11 12 '13 14
BOILER —�
BOOSTER —�
CONVERSION BURNER
COOK STOVE /
DIRECT VENT HEATER 1 i
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
I I
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER IS I 2 201 h
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST _
UNIT HEATER
INVENTED 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 E. 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 compliance with a ertinent provision of the
Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
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PLUMBER-GASFITTER NAME(o -E 6 oey 3 d re LICENSE#Jd 7``1 v 'IGNATURE
MP ❑ MGF❑ JP Al JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP❑ #>
COMPANY NAME GC.(6-o yS 11 FLrri,t,� ,Soy VC ADDRESS (4a 5e�'q-e y (•mnc-(
• CITY w' 1�r"`°`�'� STATE ►mr� ZIP at)-67 3 TEu,sue) Y3
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