HomeMy WebLinkAboutBLDG-19-006438 ,e MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t, r J MA DATE .) I I')` 11 Cf PERMIT# &Dor/ 4g.
JOBSITE ADDRESS f 3 R ci Poe- OWNER'S NAME ! b ptc,}n*S
GOWNER ADDRESS �5'a -e_ TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL e
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CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: E PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 *13 14
BOILER
BOOSTER _______I
CONVERSION BURNER
COOK STOVE 'I
DIRECT VENT HEATER
DRYER,
_
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR
GRILLE I
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
_
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST -.
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL,Ch.142 YES 'NO ❑ ,
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW 0Z/ #5-6
LIABILITY INSURANCE POLICY [1 OTHER TYPE INDEMNITY ❑ BOND L i i; LU t<< . i
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OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapte 1412;mf eil> P. r 1 -% 1
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Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1
SIGNATURE OF OWNER OR AGENT J
71, 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 compli ce with all Pertinent provision of the
s-' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMB R-GASFITTER NAME LICENSE# C�1) I S GNATURE
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MP I MGF❑ JP ❑ JGF❑ LPG' ❑ CORPORATION ❑ PA,RTN SHIP❑# LLC❑it
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COMPANY NAME mil` 9-C V 1 U 1 A ADDRESS N 7 i 1 �1 IA-go� Gra tc pd,
CITY S, Vq o Oil STATE A, ZIP 6? C 6 y TEL 6-08•) ('3 CRy
FAX CELL Sa V)S -e_ EMAIL
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