HomeMy WebLinkAboutBLDG-16-004529 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY Si V'c✓VV\ MA DATE a, I— IL,, PERMIT# 19/4-0/V5-g
JOBSITE ADDRESS Ott ' 't (9•% OWNER'S NAMEI^VWa \20v CLtmoJ41
GOWNER ADDRESS . ''10 ()AMA. TELSO 7 3-7aN(o FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:`} - RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO(Xf
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
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER ___
ROOF TOP UNIT
TEST _
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 MGL.Ch.142 YES w NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY is, OTHER TYPE INDEMNITY ❑ BOND El
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 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 7tiasce wi P inen provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t9
'L
PLUMBER-GASFITTER NAME ti=2.��¢ LICENSE# Cv-2 SIGNATURE
MP El MGF El JP El JGF❑ LPGI A, CORPORATION El# PARTNERSHIP El# Lc El#
COMPANY NAME fl1 vt:,!1 M ADDRESS /q.3 y
CITY ‘ �.v/V'ZN STATE ZIP 01(2(1 I TEL S33 1)5'N CT lrg(D
FAXS6b1.15 S'4)Q1 CELL EMAILeUj€Wtz `(12_12dTt Yl
w
X
`M
L-