HomeMy WebLinkAboutBLDG-18-004835 '�' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t Po'J le (WvL77 4- 1" �CC 5-6 (2( PERMIT#, ,'go 5—
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� y ADDRESS () W C i 10 OWNERS NAME
GOWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRENT
CLEARLY Y NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES-1 FLOORS-4 BSM 1 2 3 1 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER ______1
CONVERSION BURNER,
COOK STOVE _
DIRECT VENT HEATER
DRYER _
FIREPLACE '
FRYOLATOR
FURNACE
GENERATOR
GRILLE - i
INFRARED HEATER i
LABORATORY COCKS I •
MAKEUP AIR UNIT
OVEN li
POOL HEATER •
ROOM I SPACE HEATER -- '
ROOF TOP UNIT --
TEST
UNIT HEATER
UNVENTED ROOM HEATER '�15"' _
WATER HEATER '
OTHER _ F._ , �N`4-
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INSURANCE COVERAGE �.,/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of 11IIGL.Ch.142 YES Nd'�O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY EV---- OTHER TYPE INDEMNITY ❑ BOND ❑ l
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
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Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT j
� , I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to st of my knowledge
`-- and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. €
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PLUMBER-GASFITTER NAME 57-7 Poc LICENSE# 5709" SIGNATURE
MP ❑ MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# P PARTNERSHIP❑# LLC❑#!� I
COMPA NAME ADDRESS ! 7 L _1I( b
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CITY0...-y0a f (J STATE (�I ZIP i� ` TEL /
FAX CELL EMAILWf60 5) / P 1 /S 4 '2-'ir
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