HomeMy WebLinkAboutBLDG-19-005000 AO r P4C,EL'i
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_i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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OWNER ADDRESS 5 i?'e 4 J TEt[ 7 - _ - F X Fm,
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TYPE OCCUPANCY TYPE COMMERCiAL1 j Er-
PRINT
EDUCATIONAL El RESIDENTIAL
CLEARLY NEW:l RENOVATION:0 REPLACEMENT:C' PLANS SUBMITTED: PESO NOC�,J
PP .NOES- FLOORS-. ISM immEminiumis 6 7 8� 10 11. 12 13 14
BOILER i I 1 1 771 i . . -I f 11 11.. .,.1
BOOSTER � � �i 1 1r r ,�,
CO VERSIO BURNER 1 a l r 11.111101111161111.111111.. I Ill
COOK STOVE
DIRECT VENT HEATER I. iI( I f 1 C _ 11 11 1111 i 1 I' I. !
DRYER 1 r . .__
FIREPLACE + . _ iI I
FRYOLATOR , .I! I .,HmEE
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GRILLE: I+
INFRARED HEATER I r" _I � IL; I i �( 1
LABORATORY COCKS I .I i „i 1 •• I i i (I am
.. •.1 Fill
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MAKEUP AiR UNIT I fl if llll l'1 1 111 [ 1 1 I r. r
OVEN I. i 1'•_ i 4. I• II f 11 I I ':I
POOL HEATER 11_ ....ill, II l 11 I 1 ., ,)i..r 1
ROOM I SPACE HEATER I
ROOF Tap UNIT .l(f.I _ 'II ► I I. I I, f!1[ I1 v �_I5. II I�f .. r;lErT1HEEH-
UNVENTED ROOM HEATER I1 I C�,.< I, I I, I ...._ 1 , ( l(
WATER HEA_•g,R••_•_._._•_r ..r.___. + 1, I I I I 1 [ .1111.111114.1.. :I
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INSURANCE COVERAGE fp
I have a current liability Insurance policy or Rs substantial equivalent which meets the requirements of MGL,Ch,142 YES (all `ots
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY rip--
' OTHER TYPE INDEMNITY :r! BOND ;.,:i
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.
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CHECK ONE ONLY: OWNER 0 AGENT(,a,.,:;)
SIGNATURE OF OWNER OR AGENT ,,a
I hereby certify that all of the details and Information i have submitted or entered regarding this application are lru. `¢Ind accdratq'lo the best of my knowledge
and that all plumbing work and Insiallalions performed under the permit Issued for thisapplication will be in comillifhpe with aiKPertinent provision Oahe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ' ;'
PLUMBER-GASFITTER NAME _y_.w. ..«.« __ •....�,.,. __ LICENSE#L%1Tli�Ia +L` / SIGNATURE
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