HomeMy WebLinkAboutBldg-19-004085 51'
�'' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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is__.,6, CITY yH fmo ;LA MA DATE 1 1 R ? PERMIT*/i14d� -� wigs
�g � JOESITE ADDRESS 8 g O G`%TT WtbJ OWNER'S NAME 126t I _NIP(n ta#44 2/1
GOWNER.ADDRESS TEL FAX
TYPE OR
Pr-LINT OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL,
CLEARLY NEW:K RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO ❑
APPLI.A.NCES-I FLOORS-+ BEM 1 3 4 5 6 7
2
9 10 'I'I 12 •l, 1
BOILER �- —1
BOOSTER
_
CONVERSION BURNER, i
COOK STOVE V
_
DIRECT VENT HEATER
DRYER i
i
FIREPLACE V
FRYOLATOR
FURNACE
GENERATOR Cwis,le V
GRILLE 0ea1 V ■
INFRARED HEATER 1
LABORATORY COCKS
MAKEUP AIR UNIT R `` F j V IF it I
OVEN _.,. , .., i
POOL HEATER • _
1
ROOM I SPACE HEATER 7'i
ROOF TOP UNIT ,
TEST - .
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER
OTHER _
Oc < e U(lae1°rc V
_ I
To P,rc'pAAe "CP n(^
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Oh.142 YES ,r NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY gli OTHER TYPE INDEMNITY [1] BOND ❑ 1
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
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Massachusetts General Laws,and that my signature on this permit application lication naives this requirement.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
`` SIGNATURE OF OWNER OR AGENT
‘1-. 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
`k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance w'th all Pe inert provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l
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PLUMBER-GASFITTER NAME LICENSE# lay./2 SIGNATURE
MP MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP❑# Lc❑#
COMPANY NAME /YI 12 191 wy,I, p.i e Le_.C ADDRESS 3 4/ P,nA S l
CITY C en (✓ (-J 0 P STATE Cr) P ZIP D Q 6 3 i
TEL
FAX CELL r6, »2 9a'3 9 EMAIL
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