HomeMy WebLinkAboutBldg-17-000357 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS KITING`�WORK
a CITY: j(_l Ir �( V ► MA DA i E f41W3 P7=P,IdIT# /iF+i4r l7'f®03
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JOESITE r,DDRESS: L i I O1N1�lEP,`S NAh4E V1r1C‘..C-A._ L.J1.,�_V
(j OWNER ADDRESS: TEL: 01 1 age, F,
TYPE OR OCCUPANCY ''PE: COMIJERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL I4
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CLE_4 .LY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
I APPLIANCES? FLOOR-- I Bsnt 1 12 3 1 4 5 5 7 I 8 I 9 I 10 11 12 13 I 14
BOILER I I I I 1
BOOSTER I I 1
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I INSURANCE COVERAGE (
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO 0
if you have checked M please indicate the type of coverage by checking the appropriate box below.
" LIABILITY INSURANCE POLICY t. . 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 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information 1 have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and installations periormed under the permit issued for this application will be in compliance ' all Pr ent
provision of the Massachusetts S' ' PlumbingC�ode and Chapter 142{of the General Laws. �,
PLU MBERIGASH I I ER NAME: k \CI t Ci \(.._ LICENSE#. i• f tj SIGMA URE
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COMPANY NAME: ADDRESS: Po 60v T I9 q
CITY: tft(S\y n, , \ J STATE i`1 W\ ZIP:O D Me) FAX:
TEL: `—"f- GELLS 0..°1 LILAC-ma, _
MASTER 0 JOURNEYMAN[t LP INSTALLER❑ CORPORATION 0= PARTNERSHIP I-i- iicog
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