HomeMy WebLinkAboutBLDG-19-006278 1; MASSACHUSETTS UNIFORM APPLICATION FOR A FERRET TO PERFORM GAS FITTING WORK
M1t-k d,' Z 4 CITY -i7 YI l'X-. MA DATE J 6 // PERMIT
T* _/i, i3�/�/ � g
1 JOBSITE ADDRESS /P/ ,04 4t 6 OWNER'S NAME/f/L/i e ( iiiiik
GGWNER.ADDRESS i TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CL AtLI.' NEW:❑ RENOVATION: ❑ REPLACEMENT>r/ PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS-4. BSM 1 2 3 4 5 6 7 8 9 10 'I1 12 '13 14
BOILER — I
BOOSTER
CONVERSION BURNER -
COOK STOVE `
DIRECT VENT HEATER I I
DRYER '
FIREPLACE i
FRYOLATOR 1
FURNACE _
GENERATOR
GRILLE I
INFRARED HEATER
i LABORATORY COCKS
MAKEUP AIR UNIT I 1
OVEN
POOL HEATER -it ,
ROOM I SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER -
UNVENTED ROOM HEATER
WATER HEATER
OTHER _
_
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalentvahich meets the requirements of MMMIGL.Ch.'I42 YES jND ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYX OTHER TYPE INDEMNITY ❑ BOND ❑
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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.
CCU C requirement.
'-ICHECK ONE ONLY: OWNER ❑ AGENT ❑
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SIGNATURE OF OWNER OR AGENT
•'I• 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 corn■fiance with all Pertinent . vision of the
;`i} Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i ,,I ��
PLUMBER-GASFITTER NAME LICENSE#15�6 ` SIGNATURE
MP ❑ MGF❑ JP ❑ JGF, LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑##
COMPANY NAME Afrei �°,re ee- n/t ADDRESS 7j 5(It)/ s eC(
CITY 6/4.°57 &461 STATE /%/Q ZIP d;02- 2) TEL 91? gl*f 3!5r ' 1
FAX CELL 5,1 / .31.V EMAIL rf O Ch/! j/m edirf/01s akete