HomeMy WebLinkAboutBLDG-19-002571 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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e 3 CITY 4MleActrat QoCt MA DATE l0I 25 (t& PERMIT#naer/9110AM
JOBSITE ADDRESS 2b Ei*1CsPtLbL.em, (k,3 OWNERS NAME titih8Cs
G OWNER ADDRESS TEL lig-5S3-42/a_ FAX
TYPE OR OCCUPANCY TYPE ' COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL Er
YkINT �/
CLEARLY NEW:CI RENOVATION: +LJ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO er
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 j
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS ,
RktC C E I v F
MAKEUP AIR UNIT
OVEN
POOL HEATER Lei 5_20
51
HEATER
ROOF TOP UNIT 1LDTEST
UNIT HEATER TL�PAR—
I
INVENTED 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 [J NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY leOTHER 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
ti SIGNATURE OF OWNER OR AGENT
i, 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 tinder the permit Issued for this application will be in compliance withal Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�r�
PLUMBER-GASFITTER NAME MK3tki_ 2 %ot.Iauv..r, LICENSE#15tiy3 I SIGNATURE
MP 0 MGF❑ JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC 0 it
COMPANY NAMEtououl.+-i Orur44,kr14 kW/tint-Vs ADDRESS (ST Ua c W SWIM_ Idl .
CITY S Vn&Moon STATE t'+llr ZIP 01-CCA TEL 114 -tiq -1914
FAX CELL EMAIL Wto 1.44N4 e CvV.4t•co m,
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