HomeMy WebLinkAboutBLDG-18-002006 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ltit O - �d / *l '�6l/$OdraCITYyAra MA DATE C '� ! PERMIT
JOBSITE ADDRESS L O- _ '0,\)� - / OWNER'S NAME. I=M cc- s
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[Ek- -
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ N0❑
APPLIANCES 1 FLOORS--, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER i
DRYER
FIREPLACE i
FRYOLATOR
FURNACE
GENERATOR
GRILLE '
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER [� ' t'
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST -- . . ._ _ .._..
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER
_ I
INSURANCE COVERAGE
i have a current liability insurance policy or its substantial equivalent which meets the requirements of ti8GL.Ch.142 YES a2KID ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ II
• 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
71, I hereby certify that all of the details and information I have submitted or entered regarding this application are true nd 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 co is e • all Pertinent °vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#2 ,e7c6/' SIGNATURE
MP❑ MGF❑ JP E/JGF❑ LPGI ❑ CORPORATION❑f PARTNERSHIP❑# LLC❑#
COMPANY NAME P1--Ct tA.A QC-6 C.fI-5 1 Pr 4 ADDRESS CIQC
CITY S C STATE likA ZIP S 6-3TEL
FAX CELI?��vW"2q/9 EMAIL Pe-(wt D Rue L J / S (7 c) �((.1,'�i�r-/
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