HomeMy WebLinkAboutBLDG-19-002456 R/ a ^ �` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
%WOn=iCITY
22/020071A. MA DATE PERMIT#ag�VF d�1/U(Y
JOB ISTEADDRESS .� 4. 1,/ / A ' OWNER'S NAME Ne /u ,k_
GOWNER ADDRESS Iiv/3/1 Y! TEL FAX
TYPE OI: OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL E
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO 2--
APPLIANCES 7 FLOORS BSM I 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 1 _
MAKEUP AIR UNIT R F `(`F I4-F D
OVEN
POOL HEATER •
ROOM I SPACE HEATER I UMI -24 Old
ROOF TOP UNIT
--
TEST _. . . -. . _ . . . . . . .. ...._ ._... BUIL DING DEPA TMEINT __
UNIT HEATER by
LINVENTED 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 21.0 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ya 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
J SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application ared accurate to the b-sty of•y knowledge
�,- and that all plumbing work and Installations performed under the permit Issued for this application will be In com ce with all Pertinir1 pro n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE / 2 URE
MP"MGF 0 JPJP0 JGF 0 LP�GII 0 COR ORATION❑# PARTNERSHIP❑# n LLC
Q®# I/j5D
COMPANY NAME {'I .,L�,alrn!�/'��1 4 ADDRESS a.�I (-� anti(tl 60/7/340
l, ? R
CITY 4iO/Y.[l`�/l-- STAT ZIP C �S TEL 3 ,FY3 os Sb
FAX CELL$OK'-9,37/7SS EMAIL A 9_ eire -./a.T i or
c 31f L c° t4L
RIO -tie'?