HomeMy WebLinkAboutBLDG-17-004300 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
' - ; r77� Z . -O6-/`,I�__,�N CIT( Y4a � h4A DATE �Y� �, 2i;^� � PERMIT� -oceigeo
JOBSITE ADDRESS ? 2ClJ/ LE ) OWNERS NAME "/ /70/-15
GOWNER ADDRESS 34rtie TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ig
CLEARLYNEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO
APPLIANCES 1 FLOORS--h BSM 1 2 3 4 5 6 7 8 9 10 'I'I 12 13 14
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER !
DRYER I 1
FIREPLACE '
FRYOLATOR
FURNACE I
GENERATOR.
GRILLE '
INFRARED HEATER
LABOPATOR`(COCKS Dr-...- €
MAKEUP AIR UNIT i
OVEN � � � i
POOL HEATER1
ROOM/SPACE HEATER _1/2 I
ROOF TOP UNIT
T
TEST _
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER I !
_
- I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES .NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY`, OTHER TYPE INDEMNITY ❑ BOND ❑
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.
1
,,:_) CHECK ONE ONLY: OWNER ❑ AGENT ❑
•--, SIGNATURE OF OWNER OR AGENT .
'r b I hereby certify that all of the details and information I have submitted or entered regarding this application are true and 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 complia ce with a Pertinent provision of the
�' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. !
PLUMBER-GASFITTER NAME LICENSE# ((;IGNATURE
MP ❑ MGF❑ JF-114 JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#:
COMPANY NAME P}� c:'1€S 1).-v0 ADDRESS .D Si"kR5t-ti
CITY 5 C. `Yt-l- J-.---}\ STATE 11 L\- ZIP 0 Z>3E TEL '7 - sLer Liza 1
FAX CELL Spb ' . Z, J EMAIL S-,L'DiN% .S 1 C 1`'( P 69;1C,;"‘ /1/4-1 cr
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