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HomeMy WebLinkAboutMiscellaneous - Exception (216)MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ MA DATE 00 JI PERMIT # OMY JOBSITE ADDRESS OWNER'S NAME (�E' ��. �r /� / r OWNER ADDRESS TELF FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIALiJ PRINT CLEARLY NEW: F-1 RENOVATION: REPLACEMENT: 12( PLANS SUBMITTED: YES D NOD APPLIANCES 7 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 i - .l FIREPLACE =J l (. _I i — - FRYOLATOR FURNACE _ .. I!-1 � _ __ GENERATOR GRILLE INFRARED HEATER�J LABORATORY COCKS —I J MAKEUP AIR UNIT _. _ ._ ._ ... _ - _ - _ —Ji OVEN_1 POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT___-, TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER1 OT ER. _ — �__ __ _--� - - -- --� 1 INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 1__1 NO 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. �K ONE ON NER- I ,(I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this a plication are true and e o he b of knowledge and that all plumbing work and installations performed under the permit issued for this application ' be in complian _ IIP rtin rov' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAE )Zn7.. LICENSE # 6 IGNATURE .-.- —_ MP ZMGF EjI JP D JGF [] LPGI 0 CORPORATIO4# � PARTNERSH P ®#= LLC EJ# COMPANY NA . f a�^ _ _- _ ADDRESS _ CITY _ STATE 4.4 ZIP G TEL 4 FAX CEL ?LlS'G. �%/ EMA lid W H O O H U a w �9 - a zEl O dF1 W >- ''7 ~ W o °z W � 5 U) WLU N a o w W w CO) a z w o �y J E., a Q� x w LL w H O Z O H U W U C�7