HomeMy WebLinkAboutG-12-651 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�eLl=� CITY �OYn1a/1� I MA DATE 'f/ZO//'+- I PERMIT#
c JOBSITE ADDRESS 35" vVernvood) Villa c I OWNER'S NAME 6iai. /17a.7t4Ulin
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OWNER ADDRESS TEL 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIALE
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOV
APPLIANCES 1 - FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER if I I 1 i 1 d
BOOSTERH. 11 p p -� .7.7.1-71
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CONVERSION BURNER plJ l I r-`'•'L`.i 17,7,111,, f ®]' ,, p 1 f I1 I'
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DRYER II1 1 I n P til I 1iil
FIREPLACE
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UNIT HEATER -
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I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 2111-0 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY ❑ BOND ❑
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTERNAMELICENSE# "779Y SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION LAMM PARTNERSHIP ata LLC❑# •
COMPANY NAME: R Lr y/ Ric • I ADDRESS Z22_ Mrd- red- Oln
CITY VV. y, i. STATE MA ZIP 02673 TEL„ 574-77r-
FAX 5bf-"n1-9910 CELL --' EMAIL