HomeMy WebLinkAboutBLDG-18-005650 F
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
5 meA/1-%1 r- 9/��l�l C v�0/ PERMIT#� /�'��7a
` tff CIT( MA DATE50
JOBSITE ADDRESS 2 aQ C69'V g{2 1-4/ OWNER'S
//NAME sm 11C P C C
OWNER ADDRESS TEL 3 '9 FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:K RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES i FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 111 12 '13 14
BOILER --�
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE C i
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER I
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER • ,i•(
ROOM SPACE HEATER
ROOF TOP UNIT
TEST . . .._ .. ....
UNIT HEATER
LINVENTED ROOM HEATER •
WATER HEATER
OTHER
_ � I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES Irkd ❑
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 acc he best of my knowledge
`— and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinen vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
1
PLUMBER-GASFITTER NAME ,7/1`� redr213 LICENSE# SG041- SIGNATURE
MP ❑ MGF❑ JP❑ JGF�LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑##
COMPANY NAME ADDRESS 17 -/ o'
CITY IA- 17M IA 1- - STATE '' ' ZIP o - o TEL S� 6 VCO �
FAX CELL EMAIL IA/roe 5(7 Pp7icv /2-Oafe(S (15/f,7-i• .
L1- - • $ 6610
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