HomeMy WebLinkAboutBLDG-19-005900 ;; ,.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
9i77-67:4-V-WI
it, Vei /� '� O Y; I,�a, DATE; / �/ PERMIT#/ga$96* 00'�'x'10 J\ C€TY
JOBSITE ADDRESS 1 " v LONG d Ut,���"` OWNERS NAME (/4i , U4 of
GOWNER ADDRESS • TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL It
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [i PLANS SUBMITTED: YES❑ NO i
APPLIANCES 1 FLOORS—h c7 o1
6�IJ� 1 3 4 5 6 5 10 'I'I 12 'I; 1! i
BOILER —�
BOOSTER 1
CONVERSION BURNER, I
COOK STOVE _ _
DIRECT VENT HEATER
DRYER — I
i
FIREPLACE _ � I !
FRYOLATOR E C ! I.V D L _I
FURNACE �--
GENERATOR
GRILLE APR 1
11
INFRARED HEATER go 4r •/� )
LABORATORY COCKS IB
MAKEUP AIR UNIT ay. I Ugti '- K�M
OVEN
POOL HEATER
ROOM!SPACE HEATER '
ROOF TOP UNIT
TEST -._ .. _.._
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
_
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IInGL,Ch.142 YES.06 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE 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 wives-this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑ i
•`` SIGNATURE OF OWNER OR AGENT
4-• 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 compliance with all €neat provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .�i/ /U �
PLUMB R-GASFITTER NAME 6/ d., �d�G.) LICENSE#rift)ft) / SIGNATURE
MP i/I MGF JP JGF CORPORATIONPARTNERSHIP1
❑ ❑ ❑ LPC ❑ ❑#F ❑#r LLC.�# Q'� I
COMPANY NAME 6z./ -/ 4w4/ ADDRESS / G Ca V
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CITY (1), Q/` Ocile STATE/APIZIP 45209(a7/ TEL,'e)g;>121? P I
FAX CELL EMAI G 2Z e 0 a)4!✓y� j P��