HomeMy WebLinkAboutBLDG-23-9484 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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. ss = CITY 7)20 fj MA DATE PERMIT# QL 1'6-al 9ti
JOBSITE AD RESS /--4/, WNER'S NAME
OWNER ADDRESS 5 /7 ( TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW: 12 RENOVATION: El REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO[
FIXTURES Z FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 1
BOILER - _
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER —
DRYER
FIREPLACE
FRYOLATOR FURNACE _ /
GENERATOR
GRILLE ' D
LABORATORY COCKS r E
MAKEUP AIR UNIT -
OVEN .SCP 14 20
POOL HEATER
ROOM/SPACE HEATER gt}����rJG e,pP R MEN- -_
ROOF TOP UNIT —
TEST 1"'
UNIT HEATER
UNVENTED ROOM HEATER
—
WATER HEATER
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 1
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.
CHECK ONE ONLY: OWNER El AGENT In
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 y knowledg
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertine lion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: eiipic.e V /41/4 LICENSE#11
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COMPANY NAME: ���/9)(i2 ADDRESS: y / /3/s9/ C�
CITY: Jiff STATE: /n i 2 ZIP: lam/ � c FAX:
TEL: 7i c1 ]t Q ggri CELL: EMAIL:
MASTER❑ JOURNEYMAN ❑ LP INSTALLER❑ CORPORATION ❑'# PARTNERSHIP❑# LLC
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