HomeMy WebLinkAboutBLDG-19-002583 r • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Ji` 'J' CITY Yalema' 1 MA DATE /o -a9-rr PERMIT# FAUN?
JOBSITEADDRESS 6 FuRes#6a*G KH8f4. OWNER'S NAME cAchG Sc.
OVNJERADDRESS 6 {vKes-I' 6 Ps iC Atsr..r " 1(Pe)TVA 74. FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIALPRINT
❑k
CLEARLY NEW:❑ RENOVATION: ® REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 4 FLOORS-0 BEM 1 2 3 4 5 6 7 3 3 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR •
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM(SPACE HEATER
ROOF TOP UNIT
TEST . . . . _ e El V.t U-
.
UNIT HEATER ..
INVENTED ROOM HEATER �
WATER HEATER U�.1 Z9 2091
OTHER
BUILD ODEPARTMENfyicgi
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LiABIUTY INSURANCE POLICY X 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
lc 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. S
PLUMBER-GGASFITTERNAMEGP-E6aey�,�e LICENSE#�7"1 �° Q SIGNATURE
MP ❑ MGF❑ JP ® JGF❑ LPGI ❑ CORPORATION❑#i PARTNERSHIP❑# LLC❑#
COMPANY NAME/Very Sebe ?L„ 14,1 Sefyl ce. ADDRESS ill 5941r- 1-Ans
CITY ("• 7�him.K r STATE 11A ZIP (AR-73 TEL�'���g/y3 �f
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