HomeMy WebLinkAboutBLDG-19-001769 `• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`'`P A MA DATE PER�IT* h`,F(1° 76?
CIT(� �` ��� i
; JOBSITE ADDRESS 497ed X OWNERS NAME-' ' /` a6/, Cad,
OWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL e]
PRINT
CLEARLY NEW:Z RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO Z
APPLIANCES- FLOORS—� S ?6�Itn 1 3 1 5 6 9 1i1 'I'I 12 '13 14
BOILER
BOOSTER _____I
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR . v_.... .
FURNACE / I F l
GENERATOR.
GRILLE —� I
INFRARED HEATER ,�Ef '-.-
LABORATORY COCKS I
MAKEUP AIR UNIT I
OVEN �-y r. I
POOL HEATER 1
ROOM/SPACE HEATER I
ROOF TOP UNIT
TEST - -- - ___
UNIT HEATER _
UNVENTED ROOM HEATER I
WATER HEATER
OTHER I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of VIOL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COV RAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [�] OTHER TYPE INDEMNITY ❑ BOND ❑ I
k. 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 ❑ 1
SIGNATURE OF OWNER OR AGENT j
•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 compliant.w' II Pertinent provision of the
Massachusetts State Plumbing Code an apteofeneral Laws. _ I
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PLUMB R-GASFITTER NAME 6‘,/}erge, LICENSE# ��PD ‘ SIGNATURE
MP MGF 0 JP 0 JGF2 LPG' 0 CORPORATION 0# PARTNERSHIP 0# LLC zr# /
COMPANY NAMEC/ del Ail 16 ' ADDRESS P / o4 ' i ,'&'L
CITY(A �� STATE/'L ZIP `/ TEL��"`9'‘°/1GMl
FAX CELL EMAIL 1
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