HomeMy WebLinkAboutBLDG-18-003836 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY �J/1��1 J I:17Z MA DATE / /�3 /ic:C.- PERMIT#
JOBSITE ADDRESS / C,i "7-- e-- Ay OWNER'S NAME RA-1ZY C-i s .cy
GOWNER ADDRESS 2 G di!.,.>v i 270 TEL 3-0 72 e)£0 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL E�
PRINT ^/
CLEARLY NEW:El RENOVATION:❑ �J
REPLACEMENT:Err PLANS SUBMITTED: YES❑ NO❑
APPLIANCES- 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
_FIREPLACE
FRYOLATOR
FURNACE _
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM I SPACE HEATER �J� tJ[ )
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER /
_OTHER
INSURANCE COVERAGE ^�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES �T NU El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND El
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 El
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 of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliapce, ijh a)iPertinent,prevision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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LICENSE#
PLUMBER-GASFITTER NAME ,) ZJ SIGNATURE
MP Lr MGF❑ JP[1,F❑ LPG'❑ CORPORATION El# PARTNERSHIP El# Lc❑#
COMPANY NAME /`� / ADDRESS c) oe-Vr
CITY !5 4?I .I-S 7C'ft STATE /Y/-- ZIP co 7 6 3 / TEL S 0 2 3 ? .S /Z3
FAX CELL EMAIL
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