HomeMy WebLinkAboutBLDG-17-004303 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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": ' S s CITY .. _ - / MA DATE a ____, PERM #ADA-p-ty 9905
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JOBSITE ADDRESS 72-5 Ape 74/61ir fir OWNERS NAME
GOWNER ADDRESS TEL 2 AY
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 7 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 '
DRYER _
FIREPLACE ;
FRYOLATOR I
FURNACE
GENERATOR t --' -c-:-.% I¢ 1
GRILLE
' INFRARED HEATER 1
LABORATORY COCKS I. ••
MAKEUP AIR UNIT i.3. i
OVEN
POOL HEATER • 1 1�
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST . ..---- -- —
UNIT HEATER
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/, NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY V 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.
J CHECK ONE ONLY: OV NER 0 AGENT 0
- 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 accur 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 IS:pent vision of the
, ' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.tu
PLUMBER-GASFITTER NAME ,-1 WQ./9� LICENSE#27,1
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MP 0 MGF 0 JP JGF 0 LPGI 0 COR 0 ,ATION 0# PARTNERSHIP ■ 1' LLC 0#
COMPANY NAME a ®j7 P! ADDRESS //9"d ./ 'a .AP i Air
CITY i he_I' _ STATE/24
ZIP I / Ar TEL -IY� -a
FAX CELL EMAIL
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Maley MVII
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