HomeMy WebLinkAboutBLDG-18-004834 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ro CITY LAM RA 7-11 Ir4A DATE 8're-6 -20 6 PERMIT# ii-06-11'00A-5y
JOBS! E ADDRESS 11-1 If 1 L L. sr#- I? 0 OWNER'S NAME /--/1.An
OWNER ADDRESS TEL FAX •
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL e
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CLEARLY NEW:IV RENOVATION: 0 REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 0
APPLIANCES 7 FLOORS-+ BEM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER •
DRYER
FIREPLACE a
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER REt a V t 1
LABORATORY COCKS
MAKEUP AIR UNIT j _ �..pp
OVEN w
POOL HEATER •
ROOM 1 SPACE HEATER 3UILL) NCLi M6N
ROOF TOP UNIT
TEST uZ .......
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 [ 10 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [7 OTHER TYPE INDEMNITY ❑ 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 ❑ 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 ace tie to the best of my knowledge
`II- and that all plumbing work and Installations performed under the permit issued for this application will be In compliance wi ;NJ, i ent provision of the
} Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 77��
PLUMBER-GASFITTER NAME 51 Trig/01_,„/ )2o�j LICENSE#SAO ' SIGNATURE
MP ❑ MGF❑ JP 0 JGF['PGI 0 CORPORATION 0# PARTNERSHIP 0 is LLC❑#
COMPANY NAME ADDRESS 17 L c 0 1
CITY ''] /14V71 STAT ZIP ��TEL
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