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HomeMy WebLinkAboutBLDG-19-002327 = MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lirle CITY �"i::-W I ..-� � ! MA DATE D0 1 1-(pf i 8]PERMIT#P4/777�r�V JOBSITE ADDRESS S{"ee- Coit, g4 I OWNER'S NAME G I�- `t Lis ___ _ � OWNER ADDRESS Fin( fe.bl .,,. JTEL.c FAXL� 1 TYPE OR OCCUPANCY TYPEEDUCATIONAL PRINT COMMERCIAL 0 RESIDENTIAL[ CLEARLY NEW:D RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO® APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOOSTER • -- —= — — INFRAREDFIREPLACE FRYOLATOR GRILLE HEATER - _-LABORATORY COCKS — N MAKEUP AIR UNITOVENI - - --- __ -- -- POOL HEATER •.. . — ;-- `v ••• •. UNIT _ -- - TEST UNIT HEATER " UNVENTED ROOM HEATER — — — WATER EATER OTHER - - - ® - -� ��� ��t IN ... q INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ivistew D di I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Cy BOND El 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 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 acc . e t. e .-st of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be In compliant-. al 0i:.ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER-GASFITTER alrar _,�+ NAME[SPCW(t eit_ „14 ahe,�}' ._ _:LICENSE#111777:771, SIGNATURE MP V_# MGF© JP 0 JGF I y j LPGID CORPORATION Z#La&aqj PARTNERSHIP U4_ J LLC D#77-1 COMPANY NAME:l5etaC2t1,611e'F.1 fi.e,nb,rq •) .74-14ADDRESS�36r� 6� iia�Mo,A, CITY ImAl -b7bNS Mills it STATE all 4 1ZIP OZCP49___a rTEL[Ste -42$-CoO130 k - - - � FAXt -We-2%4E4 `EMAILNa, Ne R,� orl,\ RL '^.°' :C-L`?M iia✓ fr'd