HomeMy WebLinkAboutBLDG-19-002638 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .I
` w,k CITY ,� , MA DATE \c, 3G'la PERMIT
JOBSITE ADDRESS \ccG'S �nj1tt, A OWNERS NAME k ,s
GOWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL i EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: E PLANS SUBMITTED: YES❑ NO❑ 1
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cBEM7 u, 14 1
APPLIANCES FLOORS-- 1 3 1 5 6 _ 9 10 I I 12 13
BOILER _____I
BOOSTER I
CONVERSION BURNER
COOK STOVE _
DIRECT VENT HEATER -�
�_
DRYER
I
i
FIREPLACE s ,
FRYDLATOR
FURNACE i 4
GENERATOR I �
GRILLE !
INFRARED HEATER 4 0.4.1"
LABOPJATORY COCKS
MAKEUP AIR UNIT I
OVEN _
POOL HEATER
ROOM/SPAC;E HEATER
ROOF TOP UNIT
3 TEST .. . . . ... . ........ .
UNIT HEATER
UNVENTED ROOM HEATER 1
WATER HEATER
1 OTHER
0 1---- ,
• INSURANCE COVERAGE
Gi I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO D-
O I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE` GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ► OTHER TYPE INDEMNITY ❑ BOND ❑
CI) 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_IN 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 corn 6 lance w:h all Pertinent proviso f the I
`` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �,�
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PLUMBER-GASFITTER NAM- LICENSE#a61'Job SIGNATURE
MP ❑ MGF❑ JP DeJGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# I
COMPANY NAME �\\�i-4.,, k\4M, t ADDRESS a`a ,,r %c1�_
CITY V . C STATE '" Y\ ZIP QZ.CA(,•CJ TEL Z4R "'Z2\ZAN
FAX CELL EMAIL
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