HomeMy WebLinkAboutBLDG-19-001778 --tom
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
NSW,` ro fn4 DATE �')Zy)jY PERMIT 0 AZ-Di �� mF
CITY c,f..y,� MA OG
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JOBSITE ADDRESS 7).I ) )bs-i - 0 r, OWNER'S NAME �"t''4 rid c i c 614e
GOWNER ADDRESS TEL FAX
TYPE OR. OCCUPANCY TYPE COMMERCIAL❑ FDU�ATIGJAL 0 R�
SIDEJTIALPR/NT
CLEARLY NEW:0 'RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ 1\101Q
APPLIANCES 1 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/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER C rvra
LINVENTED ROOM HEATER
WATER HEATER
OTHER P ` ,
cm- DL PAR - T
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 10 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY'j OTHER 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 ❑
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 compliance with all Pertinent r Ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME 11.7a" 61yis•-• LICENSEE 2G a SIGNATURE
MP 0 MGF❑ JPt JGF❑ LPGI 0 CORPORATION❑It PARTNERSHIP 0 0 / LLC 0 ft
COMPANY NAME '� WADDRESS 23 5L 1k-
CITY Y 9'rn C. -L STATE kM.4 ZIP (}2 3 G G TEL
FAX ! CELL JY) 53/ Cls EMAIL
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