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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL LI RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:(, PLANS SUBMITTED: YES(,.; NO0
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INFRARED HEATER
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MAKEUP AIR UNIT l . s{..._.. t l 1 <�1Y «i, i r 1( .J. , [I `Jf i'., 11 <irr : T, _1
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ROOF TOP UNIT
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UNIT HEATER i t UNVENTED ROOM HEATER ,1::::sJ e .Ji• . .11(. _:1li.:L_...A' L+ "...1`S.».}!1f.a, 1i'f=s.-rc:1I tI -." 1"i..a.2.-�?-42+t.-y1 cI tA 'i .ti ir-.f_:::1 I `t f de
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—.�,. INSURANCE
COVERAGE .1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch,142 YES UNTO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [uC. ^. OTHER TYPE INDEMNITY [ 1 BOND 1.."
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 El AGENT 1:::(
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru lnd accarateito the best of my knowledge
and That all plumbing work and Installations performed under the permit Issued for this application will be in corapliiifne w el aljPertlnent provision of the
Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. <A.' v,:::—
PLUMBER•GASFITTER NAME L c .s __,_,,,_..�,,,,Y,., LICENSE#i,.;!�,r+:9„/it ;" SIGNATURE
MPAI MGF(.;I JP El JGF[�.I LPGI Ll CORPORATION[ # q .iJ PARTNERSHIP DC: i LIG, #IwW-�Ti
COMPANY NAME c 'f.1:11 7 // ADDRESS t " Aof
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CITY -, 1r,.::.Y i .•,N•••: . ,. zu. STATE L,s ZiP te ITE< Lm: ..»<....... .,.. w..,w.....�.��J
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