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HomeMy WebLinkAboutBLDG-18-007400 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK TRW ' / 1-4:7111W CITY 50-7/ V444,7ner7<j MA DATE Slit/li PERMIT# 046-/r-do 7V0 JOBSITE ADDRESS / �Z ?I tak g-j, 3.7 OWNER'S NAME V4v 1 A A e & p,u G OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL p-******- PRINT —/ CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:LK PLANS SUBMITTED: YES 0 NO tie.' APPLIANCES 1 FLOORS-. BSM 1 2 3 4 _ 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE t DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS p MAKEUP AIR UN . G E E OVEN POOL HEATER 20111 ROOM/SPACE HEATER ROOF TOP UNIT .-- . nTra NT TEST ©UtLUtNL tJEt� UNIT HEATER By 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 r1 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IRAOTHER TYPE INDEMNITY 0 BOND 0 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 0 AGENT 0 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 complia ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 oft the General Laws. ER- PLUMBASFITTER NAME Ochi- ✓ 4,4%/4 -d / LICENSE#//777 SIGNATURE MP Ly' MGF 0 JP 0 JGF/❑ LPG!El CORPORATION # PARTNERSHIP 0# LLC 0# COMPANY NAME cA-pt (4 I'M IN C. ADDRESS ?. 0 . /5'!X '-! 27 CITY ,S 7 t.UN f f STATE /In- ZIP D 2 6 6 0 TEL sap -79 FAX CELL EMAIL L-j 19 )d° •