HomeMy WebLinkAboutG-18-4980 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t CITY / mOu l0, MA DATE ,274/2____ PERMIT# /T-cO! ?
JOBSITE ADDRESS g( ki AS' Cl f-CU.1 I OIMJER'S NAME
GOWNER ADDRESS Tit otrr fl'. .TEL FAX, •
TYPE OR OCCUPANCY TYPE COMMERCIA EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENTS PLANS SUBMITTED: YES 0 NOV:
APPLIANCES 7 FLOORS- 5810 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER _
DRYER I
FIREPLACE
FRYOLATOR •
FURNACE /'7ZZL 6
GENERATOR
GRILLE
INFRARED HEATER __ •
LABORATORY COCKS .
MAKEUP AIR UNIT
OVEN
POOL HEATER • R fV E IN € n
ROOM/SPACE HEATER —' a i
ROOF TOP UNIT1
TEST — . AR 0-5 Gia
UNIT HEATER
INVENTED ROOM HEATER BUlL I ' I k i i
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 trNO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 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 pliance with all P rtlnent p ov' ion of the
Q.,1Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER, NAME LICENSE# ? SIGN RE
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MP ;GF 0 JPJGF�0 LPGI 0 CORPORATION tit 4000 PARTNERSHIP 0# LLC 0#
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COMPANY NAME Q tt teA-T1b6-1-CC)Li 11, 9-ADDRESS 50Ifl tisS* b,e e
CITY /M2-414 Ott/ STATE Cl'V r ZIP 0�7a— TEL 5os-?37/ l
FAX CELVnQ ..--)z> gEMAIL '0.M C 6i�✓1Q111*C "
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