HomeMy WebLinkAboutBLDG-19-001777 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
oa, CITY Ic! rw ` edt4- K A DATE 7/1 V/''i PERMIT#
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JOBSITEADDRESS 2jo5 A/4s-+ L1 Lifcci OC , OWNER'S NAME ( Lf\o\ aeantf`
OWNER ADDRESS TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL CS,
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: ] PLANS SUBMITTED: YES❑ NOIEI
APPLIANCES 1 FLOORS-+ SSM 1 2 3 a 5 6 7 8 9 10 1.1 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER f
FIREPLACE
FRYOLATOR
FURNACE 7
GENERATOR -
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST R E 1 E
UNIT HEATER •
_
LUdVENTED ROOM HEATER
WATER HEATER S 1 2 Ir
OTHER
BUILDI" ,[)E'p RTM=N7ut
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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 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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.
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CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
‘,l, 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 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.Lij
PLUMBER-GASFITTER NAME trn 01433. LICENSE# Z&2- GNATURE
MP❑ MGF 0 JP isz JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP❑# LLC❑#
COMPANY NAME t3 bVsr-. 9-1 H ADDRESS 2 :� §heJjav ,..w/ Ln
CITY `Pl7n.r kSTATE i'44 ZIP 013b0 TEL )r) 83/ c54-Y
FAX CELL ) p) 'k31 • 5" W EMAIL
ic-P4A1- - 6/73 9it
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