HomeMy WebLinkAboutBLDG-17-001780 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`��n•�6 MI DATE PERMIT* `_
��s, CITY ylzI ��'�U � /�L�(�"`7 0 MO
JOBSITE ADDRESS 0 OWNER'S NAME 1 - d\ c41
GOWNER ADDRESS a to (( TEL N7 - FAX
TYPE OROCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
PRU T
CLEARLY NEW:Z RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--F
6..IJ� 1 2 3 4 5 6 9 10 'I 1 12 '13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _
DRYER,
FIREPLACE
FRYOLATOR
/ . „
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER T
LABORATORY COCKS •
MAKEUP AIR UNIT
1 OVEN
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST (.7) l
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.1142 YES �Q ❑
' I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ 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 ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ccurate to the hest my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian with all Pertinent vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER-GASFITTER NAME LICENSE#.c('/ SIG ,
MP E MGF❑ JP❑ JGF I� LPGI ❑ CORPORATION ❑## PARTNERSHIP❑#r LLC❑
COMPANY NAME . 6iikl t Q Lk4Q-1e ADDRESS pd PA3' e 1)
CITY (r. \( VA O UT H S ATE l�4- ZIP O CO TEL 4695-J15?- �
FAX LL CELL EMAIL4PV r -� c,,,i,e 6 ingt
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