HomeMy WebLinkAboutBLDG-24-82 :.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS OWNER'S NAMIrt, 4E1NT
GOWNER ADDRESS / c �cger 1 TEL ! /`7' /!zf`�( l 73 FAy
Ti YPE OR OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL®�
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CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS- 6SM 1 2 3 1 5 69 10 11 12 '13
8 14
BOILER ■■■ ---IBOOSTER _J
CONVERSION BURNER
COOK STOVE 1.1
DIRECT VENT HEATER —1
DRYER
FIREPLACE
FRYOLATOR A--_ _
FURNACE 111 —
GENERATOR
GRILLE
INFRARED HEATER I
LABORATORY COCKS E' ,.; G L 1 P
MAKEUP AIR UNIT I
OVEN ! _ 3e
POOL HEATER , t
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ROOM I SPACE HEATER ___ _WI'
ROOF TOP UNIT __ _C_ ' BUi _DIN uti
TEST ... !_,.. ........ - • ---
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER
OTHER ■ -1
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 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 l
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
-, CHECK ONE O LY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
,4-, I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate to the f my knowledge
`; and that all plumbing work and installations performed under the permit issued for this application will be in corn nce with all P i ovision of the
N'` Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE# SI ` R
MP ❑ MGF❑ JP❑ JGF[`l LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME AOU itg HEAT-A f r- 1 NC i ADDRESS �/Q 17 VAM 7_
CITY PI )vho L) r W- C� -,STATE f 11�f. ZIP C�3 CC) TEL 7Ce - I67- '�)6 06
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