FEB 2016 P&G TG-17-79 APP MASSAPPLICATION
.. US APPL.I ATION FOR A PERMIT TO PERFORM GAS FITTING WORK
HLISELTSUNIFORMMA DATE
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I'VVE OR OCCUPANCY TYPE CC1NIMCRCIAL EDUCATIONAL n RESIDENTIAL
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�" �j REPLACEMENT, � PLANS StJEC�TITTEC YES�] FJC?�9
mAPPL'IA�JCES "� FLOORS— � �,��.,,�, .�.� ._.,...,. _. ........__..�.. _ �_....._.�. ......_. _..
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DIRECT VENT HEATER
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FIREPLACE
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INFRARED HEATER--,,-
LABORATORY COCKS
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ROOM 9 SPACE HEATER
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UNIT HEATER
UNVENTEC RCIOm HEATED I
WATER NEATER
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INSURANCE COVERAGE
i have a current flabilit insurance policy or its substantial equivalent which meets the requirements el MGT,.Ch.'142 YES E] NtT Lj
IIF'YOU CHECKED YES,F°i.CASE INDICAII TILE TYPE Of COVERAGE BY+CHLCKfNG THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER:I am aware that the f Censee does not hav�M the insurance coverage requwed by Chapter 142 of the
ttassachuse s General La and that my st nature oil this permit application waives thi-,tequirerrtent. !
CHICK ONE ONLY. OWNER � A R
GENT � "
SIGhJATU E OF OWN OR AGENT 5
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el .� ;at the:�delwiS a:d aratarm tiara I ut:4xon d ear enteted rvgc ,xdioj lives jvpi,c a!x)n are 1'rt r ano.rt,cutate to l+y,,r b st at nay kr�a v1r..rr
a1w thm pa:i p9'ornbing worix rancl itW allattur S rb1`kyrrr(W e;'rrder the permit issueo!ar this app;icatrc.ra wil be hn cc,mpt ,ance witn,aN PerkPr;wnt prv°;Waken of tk,r.»
1 as a:7u its State P'Yunib4lg C+>Je grid Criavler 14�of the Gerrard Laws. ,ICaq w
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PLUfA6E� CAS,FITTER NAME LICEN"E n �� �-° � U C` :.. .._. _...
tiip &IGF[] JP JGF LPGI CORPORATION # PARTNERSHIP 4 LLC
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