HomeMy WebLinkAboutBLDG-19-006572 KAASGACHUGETTS UNIFORM APPLICATION FOR A PERMIT TOPERFORM GAS FITTING WORK �
CRY MA DATE PERN[[�����^
J08S|TEADDREGG OWNER'S NAME |
GOWNERADDRE8G TE '----'-------- FA<
TYPE OR OCCUPANCYTYPE C0MMERQAL�� EDUCATIONAL RESIDENTIAL[
P30URT '~^ /'~� ="
CLEABN~Y NEVV �� RE REPLACEMENT: PLAN8GUB��TE�� YE8'.�� N0��
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APPLIANCES FLOORS- ouw i 2 o 4 5 o / 8 8 10 11 12 @ 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
FIREPLACE r,
FRYOLATOR
FURNACE [7—
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN 71
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT E71| |
TEST L |
UNIT HEATER
UNVENTED ROOM HEATER
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WAJERHE/TEfL________-____
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INSURANCE COVERAGE
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|have axunentUobU|b/inmomncopolicy o,i�substantial equivalent which ma�sthe mqu|mmontmofMGL Ch.142 YES ��NO
||F YOU uHeCKEDYESPLGoSEINDInATE THE TYPE OF COVERAGE aY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND-_1
OWNEFVS 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 AGENTAGENT �-|
SIGNATURE 8F OWNER 0RAGENT
uv certify that all of the details andInformation|ham submItted or entered regarding this application are true and accur"e best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance rov on ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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COMPANY NAME|8 Hu|| d� b� dHmd|n | ��DDRE88 i0dFu| �Rd Unit 3G ��'uPemm[_mm_�ummn�anog�-nc ��_' '- -nn�n}��.-_- _ --_-__--_
CITY ----- ---'-----'- - � E[-��-�Z|P ----XTEL -
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FAX 10CELL~~~ EMAIL encer@hallettplumbing.com........-.--.. _________.
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