HomeMy WebLinkAboutBLDG-17-000511 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
teeth CITY h11 ( I(V 1(-) INh MA DATE 7-a9- l(9 PERMITS/fr4k /7--C1 57/
JOBSITE ADDRESS I\ l ,( cn \S.6CSA- OWNER'S NAME Ljxk4 frit Qr
G owNERADDREss&SE, Nor{ kky{�,, Uxbrldp OI 1 _
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL Ly"
PRINT —/
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 12"
APPLIANCES 1 FLOORS' BSM 1 2 3 4 5 6 7 8 a 10 11 12 13 14
BOILER YfwoV J ._r ' a,
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
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER 'T WO_ li Y1P S - t — _
INSURANCE COVERAGE /
I have a current liability insurance policy or its substantial ,�
ial equivalent which meets the requirements of MGL Ch. YES RIO 0
IIF YOU CHECKED YES,PLEASE INDICATE THE TYPEOF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L: OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:1 am aware thatthe 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 El
SIGNATURE OF OWNER OR AGENT
I hereby certify that al of the details and information I have submitted or entered regarding this application are true and accurate to the bast oEmy.knowledge
and that all plumbing work and insteeationa performed under the permit issued for this applcation will be Inancewith all Pertinent provision e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER.NAME Cc CU 3 p LICENSE# I-6IoI n SIGNATURE
MP Ele MGF❑ JP❑ JGF❑ iPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME I42I3I'1 -Ft't-(C�t.Q'flC-l. ��yy t^ ADDRESS 37?) !'Rlott+P )i 0
CITY San ____ STATE X ZIP 0P, (.03 in SOR-8L5- 3(995
FAX CELL EMAIL ilia. S t• ' ' ' -'/ . 11 . , u
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