HomeMy WebLinkAboutBLDG-19-003554 ,r • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Wiwi' CITY 7/t ✓LtoceThe MA DATE 4-1/—/F PERMIT ft- •17bI9-d0/5537
JOBSITE ADDRESS !YV/ ,c4/,CIlt IXI,O LW OWNER'S NAME/Y/GGLZ
Cr OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL�--
PRINT
CLEARLY NEW:0 RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO®--
APPLIANCES 2 FLOORS-. BSM 1 2 3 -1 5 6 7 8 5 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER —
COOK STOVE
DIRECT VENT HEATER —
DRYER _
FIREPLACE
FRYOLATOR —
FURNACE —
GENERATOR
GRILLE
INFRARED HEATER -
LABOP✓ATORY COCKS 1 R _ (j E S �J ,
MAKEUP AIR UNIT
OVEN —
POOL HEATER I
DEC 1 28161
ROOM!SPACE HEATER
ROOF TOP UNIT
RUILDIN 3 =t•t Tk M.N I '
TEST ... --
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER
Z
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES iO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
- and that all plumbing work and installations performed under the permit Issued for this application will be in compiianpe with Pertinent provisionthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �J/
PLUMBER-GASFITTER NAME ft- C61-4.0 4704775 41— LICENSE# ne/ SIGNATURE
MP s rmGF❑ JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME /Z447sCr /21-#- ADDRESS 7 /"L/ ,(%J-vr /'.e?tf.0 C//I_
CITY 4.144eenCl STATE I.C4f ZIP UV-G93--- TEL flA>Z37�..17`Tj
FAX CELL EMAILC4a7ar 1°,€544 a aopvfC„Zft rp —
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