HomeMy WebLinkAboutBLDG-15-001463 - ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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3`'4�=_;' CITY We ST. liN2 m ur.c11-4 • MA DATE 9/a311 q PERMIT#P-1,6•-17-0°/1114
JOBSITE ADDRESS 17 V/t91 AEA 94- OWNER'S NAME GAs^rrr * �t utg 8ufNaW
GOWNER ADDRESS 1, • TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL w
PRINT
CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:W PLANS SUBMITTED: YES 0 NO❑
APPLIANCES 1 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
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT EATER
UNV NtEDROOM HEATER E 0
WAT R T Q r f r/ )
0TH R t.E���.�rr "](�
SE? 2bZUllt I
6UILL)'G L (.IENT
I -- INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 2 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.
CHECK ONE ONLY: OWNER 0 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' comp iance with Pertin nt pr sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME'JG five y -571)215€oL-L LICENSE it /,TL SIGNATURE
MP MGF 0 JP 0 JGF 0 LPG'0 CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME JEff2EYnet cent /L414Nfq ADDRESS HS Rounrb ave Kcf
CITY £/tsr -litr•4:L Dreg STATE ` 14- ZIP 6" Yr TEL So e -Y-n -8974
FAX 57141 CELL 71N-353- Ga/ a . EMAIL pu44-in 9 plunr h.e�' t2. yahoo. Corn•
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