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HomeMy WebLinkAboutBLDG-19-002615 - � - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK t `9 �v� - ssk CITY fl?P r /Y 1nlv,.-c h MA DATE 43--_3o�-i ' PERMIT#f Of'/P-irti4/f- JGBSITEADDRESS ACC _�Jcl re- AA.P•e OWNERS NAME in/e �, r,/it. C- OWNER ADDRESS Y 0 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL. PRINT CLEARLY NE'W:A RENOVATION: 0 REPLACEMENT: ❑ PLANS SUBMITTED: YES 0 NO 0. APPLIANCES 2 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 BOILER BOOSTER CONVERSION BURNER — COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR - FURNACE K b C GENERATOR I GRILLE INFRARED HEATER OC1 3 0-2018 LABORATORY COCKS MAKEUP AIR UNIT tiL1 rNb utr'Ar<r nn:rJT i OVEN — a, — POOL HEATER • - ROOM I SPACE HEATER ROOF TOP UNIT TEST ._.- --._ - . -- UNIT HEATER INVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE rn I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES /,,NO 0 IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYf OTHER TYPE INDEMNITY ❑ BOND ❑ 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 t-J,:; I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurateb o Sedge and that all plumbing work and Installations performed under the pennk Issued for this application will be in compliance with- �' . pr ' ion of the ,, Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME (lite-,,,c1I1/4 (/wer _ LICENSE# /rr7D SIGNATURE MP MGF 0 JP❑ JGF 0 LPG ❑ CORPORATION WiJl Mel PARTNERSHIP❑# LLC❑# COMPANY NAME fiery ' ' 1r.ainiditst/ly ADDRESS ,..2-er 64e.E Giio>' s% CITY j'Tia/o,i . STATE 114- ZIP ©907a- TEL l FAX CELL (1/7-3n-0739 EMAIL /Z-..-.2.1 ( %Ji/[.(at tva/2�7 +,/ / // fi y -2A9' y7/1V