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HomeMy WebLinkAboutBLDG-18-003775 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a v /2-;;PJ-)7: PERMIT#/L)6 /Y-CO' S� WI CITY yCYr''v^_'. .pp ,.�'//' a- MA//DJJATppE /j� JOBSITE ADDRESS 4 ti I�JG/C N! `Pr� , . I L &WNER'S NAME ,I C G OWNER ADDRESS T. - { sty 21 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL _,! EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:/ PLANS SUBMITTED: YES .: NO 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 l DRYER I �/ FIREPLACE FRYOLATOR FURNACE J / GENERATOR • GRILLE / • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM ISPACE HEATER ROOF TOP UNIT TEST UNIT HEATER G./ 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 40 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGEOVBY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY . OTHER TYPE INDEMNITY : BOND I 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 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 co Ic 't al rtinent r vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME .44 A.au . LICENSE# //yj SIGNATURE MPLMGF . JJGF ; LPGI CORPORATION # Y ,.._' PARTNERSHIP .. :# LLC . # , COMPANY NAME:_ Cieclef // f 1 (.. j ADDRESS r /JG/hc _._ . __ ._.,...... CITY ©.....S...... STATE M9-.ZIP 024.c3 TEL . _(2g1.2.<57/090. ... . FAX CELL EMAIL •• F •