HomeMy WebLinkAboutBLDG-18-007341 .--' .MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY y"ilG at MA DATE e1/47/fr_ PERMIT#/4L � ni,
JOBSITEADDRESS 2t�CH-04^-e-A S7- OWNER'S NAME 1L€ oo.
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:7 RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 s 9 10 11 12 13 14
BOILER ( 2g -
BOOSTER
CONVERSION BURNER
COOK STOVE (
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS -
OVENUP AIR UNIT pc E
POOL HEATER •
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ROOM I SPACE HEATER Jul `1. 1 j
ROOF TOP UNIT I
TEST L.-- 4
.._... 'Htt7 y?GJ i 3
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 NO 0
I F 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.
CHECK ONE ONLY: OWNER 0 AGENT 0
-, SIGNATURE OF OWNER OR AGENT
ta„. I hereby certify that all M the details and information I have submitted or entered regarding this application are true and accurate to the ber if my knowledge
`- and that all plumbing work and Installations performed under the permit Issued for this application will be In corn co wl all Peru yr/7. of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �►
PLUMBER-GASFITTER NAME O en tttt - Cii -Ck& LICENSE It 10894 SI ATURE
MP MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC 0#
COMPANY NAME do . C/#RC k4 ADDRESS 137' rt A-1-1 ar
CITY C.d G-IJ STATE rAA- ZIP 03-64" TEL Sb A,-. 9 q 731/
FAX CELL EMAIL
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