HomeMy WebLinkAboutBLDG-18-001946 �. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK1 jj
I % o r MA DATE /O 3 PERMIT
p � CITY #.49lT`18'47U/:?q6
JOBSIT ADDRESS I l'(2- -2 OWNER'S NAME /Ja
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDW.' TIONAL ❑ RESIDENTIAL(AlPRINT
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CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 _ 8 9 _ 10 11 12 13 14
BOILER
BOOSTER _
CONVERSION BURNER,
_ __
1HEATER ��
—1
FIREPLACE —1
GENERATOR. -
- l
. INFRARED HEATER
7, IOAKEUP AIR UNIT
POOL HEATER •
—
ROOF TOP UNIT ,
_
UNIT HEATER
LINVENTED 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 MGL.Ch.142 YES �NO ❑
I IF YOU CHECKED YES,PLEASE.INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW i O
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 j
-• I hereby certify that all of the details and information I have submitted or entered regarding this application are true ,no 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, /-wit ertinent provision of the
Massachusetts State Plumbing Code and Ch erR-; '142 of the General LawsLi) . ,/ /,
PLUMBEASFITTER NAME LICENSE#//di? SIGNATURE
MP ! MGF❑ JP ❑ 2)//' "- -
F❑ LPGI ❑ CORPORATION❑# PARTNERSHIP # tic #
COMPANY NAME/' 4i 4 ADDRESS "- 7 ?-, /Qve
CITY /1 STATEfitAt ZIP TEL J OY 2 /2,74?
FAX CELL EMAIL field es r?g
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