HomeMy WebLinkAboutBLDG-19-002381 .. --,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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s CITY 1141 a1 O V MA DATE IP '/9--/k PERMIT# *Db i9-002/r
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JOBSITE ADDRESS y - J roSA✓Q f`C.O,L OWNER'S NAME
GOWNER ADDRESS SfM..? TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION: 0 REPLACEMENTt PLANS SUBMITTED: YES 0 NO❑
APPLIANCES 1 FLOORS-+ BEM 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 _._fr:'— . — ' -t
LABORATORY COCKS (% �_ r
MAKEUP AIR UNIT J L
OVEN 1 A.T t , zc n yl I
POOL HEATER ff j
ROOM I SPACE HEATER - J 1
ROOF TOP UNIT
5- r., ,L,Nr I
TEST -- , _
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 El-1110
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY ILI— 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 ❑ 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
3- and that all plumbing work and Installations performed under the permit Issued for this application will • • rice with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTERNAME LICENSE#P67-�G SIGN RE
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COMPANY/ NAME 2 c4aaj Lc , / )i \ ADDRESS l Z/1Qii- 0- —
CITY The/20,7/_' n STATE 1?# ZIP O'M/ G TEL -f e-3sa$ -Z/7
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