HomeMy WebLinkAboutBLDG-19-003557 L>iv7f� V
MASSACcIUSIE T T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY r f 16-11.
L- t 1 .. MA DATE 17-/b/� /'q PERMIT#�,7�/'G7�r-GG :1531
^*J� JOBSITE ADDRESS ''� TEL ..._ .!A,,'k11L� OWNER'S NAME
OWNER ADDRESS I.. 9 1 ..-Mad(54/1,:_j Je, GSiufhyd V FAXt
TYPE OR .._.
PINT OCCUPANCY TYPE COMMERCIAL ✓
EDUCATIONAL[ RESIDENTIAL
CLEARLY NEW:E. RENOVATION: REPLACEMENT:
PLANS SUBMITTED: YES _'� NOD
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ,i • I ---
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 = - w _
UNIT HEATER -
UNVENTED ROOM HEATER .tC .-' =
WATER HEATER - -
OTHER
•• I _
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_. _. :Uuit4.alL.._. TP1 7T
INSURANCE COVERAGE I �/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES reN0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY TV OTHER TYPE INDEMNITY 7 BOND C:
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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER AGENT El
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and act : e t• I e .,-st of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In compliant- i al -ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
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PLUMBER-GASFITTER NAME SQcv.(CL• 1-14Wkk} a LICENSE# (teat SIGNATURE
MP'1 " MGF D JP C; JGF LPG'( v CORPORATION Elf 3g ' PARTNERSHIP_- #L LLC C'#
COMPANY NAME SQ.ea9Ci2Ureit ,aenLq '1J-t.w ADDRESS . , b 100,,.4Rn M {3t -_--
CITY !MAR-S-COtJS M6Urj STATE EMI ZIP!O2fvy$ TELSte-Lae (POgp �.
FAX5f2 '�MELD
EMAIL
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