HomeMy WebLinkAboutBLDG-17-000409 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADORES: U 7 i-e\o e Dna _ OWNER'S NAMEI ' _p_ L9 S
GOVINER ADDRESS 'l / ( ]WA y/3-859-51016FAX
TYPE OR OCCUPANCY7YPE Com92CIAL❑ EDUCATIONAL ID RESIDENTIAL
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CLEARLY NEW 0 RENOVATION:❑ RFPI.ACEIAENT 0 PLANS SUBMITTED: YES 0 NO;
APPLIANCES 7 FLOORS BSN 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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NSURANCECOVERAGE
1 have a current liability insurance policy or its substantial equivalat Wick meets the requirements of MGL Ch.142 YES,NO E
I F YOU CHECKED YES,PLEASE NDICATETHETYPE OF COVERAGE HYCIEOOIG THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCYI4 071ER TYPE NDEIMITY 0 BOND 0
OWNER'S INSURANCE WAIVER I am awn that the Haase.does not have the'narrate coverage required by Chapter 142 of the
Massachusetts General lawn and that my signature on this permit appieation vis this requirement
CHECK ONE ONLY: OWNER AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby candy that a.ogre details and information 1 have subrrited ar added regaling this appidian we true and acuate to the best of my knowledge
and that all daubing work and istaiarias pertained under the pent®red for this appication us be In arnplance`e tySA.� nt provisan of the
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Massadwetts State Pkbkg Cods aChapter upter 142 d the General Lac
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PLUMBER-GAsTER NAME 1 MA RS I.oruJ&'dl 1 LICENSE Wicettri SIGNATURE
MP ' MGC1 JP 0 JGF E ILPGI❑ CORPORATIONS#knife. PARTNERSHIP D#j i LLC n# -!
COMPANY NAME?LOI 1<t) lgvn airli—f l t<R nd ADORESSI V-3 Lincoln .4dc '
cin' = Phznn yr ll e_ I STATE 7/7.311 ZIPk./v74*a ITEi(Stt-conn-d5 6-9 I
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ROUGH GAS INSPECTION NOTFO THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 f&- iC/ 61/513
FEE: PERMIT
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FLAN REVIEW NOTES
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