HomeMy WebLinkAboutBLDG-17-003218 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESSy oqg Sr 1YQv ._ at 1r1►ci OWNER'S NAItE' f �. _ &�Ili,F .I IG _
GOWNER ADDRESS E __ _ TELL 'FAX i
PRINT°R OCCUPANCY TYPE COMMERCIAL, EDUCATIONAL 0 RESIDENTIAL= .
CLEARLY NEW:. RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES - NOS
APPLIANCES 1 FLOORS—, BSM 1 2 3 l 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER ,
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
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DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
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INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN {
POOL HEATER
ROOM I SPACE HEATER :+.. . ;
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
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WATER HEATER �__
OTHER L ,�
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES K NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE LOX BELOW
LIABILITY INSURANCE POLICY ,k OTHER TYPE INDEMNITY BOND j
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 requirE ment.
CHECK ONE ONLY;; OWNER ' AGENT ,.,..
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application we true ar. accur-6 to t.- :- t of.• knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in i i•, wit -II Pe ' ent pr•,:Si.: . the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t f
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PLUMBER-GASFITTER NAME 1 el S tv f!i r r 1`� t`l) LICENSE# l C 7t SIGNA URE
MP MGF JP EJ JGF ..J LPGI El CORPORATION! # PARTNERSHIP EittiL� `i LLC #
COMPANY NAME! 5.t i erl`S 0141.446 tilp ` / ADDRESS PO 0 6x r,
CITY t41 e$1 . yi?I (it. .w _.._ STATE !ZIP L4,2 `. , f._,
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