HomeMy WebLinkAboutBLDG-19-001677 Sts. MASSACHUSETTS G UNIFORM, APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY , YticA-(DG' L Z"7 • MA DATE 5/Z-54 I PERMIT# l�G�/26--R !X��JOBSITE ADDRESS 10E r3 � WNER'S NAME �c���/
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G OWNER ADDRESS cliask L • TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 - RESIDENTIAL&
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
APPLIANCES T 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 •
UNVENTED ROOM HEATER
WATER HEATER
OTHER X
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nittute
INSURANCE COVERAGE ????,,,,����''''
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES- O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW '
LIABIUTY INSURANCE POLICY \ OTHER TYPE INDEMNITY 0 BOND ❑
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 perk Issued for this application will be In co Iia ce wi II edinent pSpvision of the
Massachusetts State Plumbing Code end Chapter 142 of the General Laws.
IC 0121-0•V 4
PLUMBER-GASFITTER NAME Ai/Cr{AttLA/ t2 -C .Vt LICENSE#//475 IGNATURE
MP 0 MGF 0 JP 0 JGF 0 LPGK CORPORATION 0# Po - Bok
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COMPANY NAME , �cVVL7e/t� - YROpiavA— ADDRESS f -o - Bok 17�y
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C5- l�vAI S STATE--M' ZIP �01666 TEL k ? o arz7
FAX ?1,0U if CELL i f J F�Or l i/V EMAIL •
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