HomeMy WebLinkAboutBLDG-24-609 Ui ) 5 Li 00 U G\--- 6 0.0E
gl. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS -��eIi 1- OWNER'S NAME_ L I ')(-
GOWNER ADDRESS '511--- TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: LE — PLANS SUBMITTED: YES NO❑
APPLIANCES 1 FLOORS• BSM 1 2 3 4 5 6
7 8 9 10 11 2 1� 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER —I
1
DRYER '
I
FIREPLACE
FRYOLATOR
FURNACE —81
GENERATOR rRcTTT j
GRILLE 1I
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INFRARED HEATER _� i QC1 _0 201 1 1 i
LABORATORY COCKS •\
MAKEUP AIR UNIT : —1
OVEN - t t. 7.7,- _ r
POOL HEATER • b—`1Y
ROOM I SPACE HEATER 1
ROOF TOP UNIT
I
TEST
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IUIGL.Ch.142 YES D U
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE ::CKII4G 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 waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
1, 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 h all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAMEE6---Ai D�`�-M J9./V'Tt�j,�o lSE# )�C.196 SIGNATURE
MP ! MGF " JP JGF LPGI E CORPORATION❑# PARTNERSHIP/ � El# LLC❑#
COMPANY NAME 1 I 6 / / k) ADDRESS z_ ARi- " /L ' " e�CITY VrLi\'1oy `V T4 STATE 4 ZIP TEL. V c 3&.0
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