HomeMy WebLinkAboutBldg-20-000305 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY SQu X y.�!i,'Y24,i7/i MA DATE 7'//Tl/S PERMIT#&Ol9'120' c
JOBSITE ADDRESS 37 n7O0 i'/Ad f Gem'-c— OWNER'S NAME -ace/
GOWNER ADDRESS TEL FAX
RTYPI1�tOT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL � 61370-0)
CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:Er PLANS SUBMITTED: YES❑ NO❑�
APPLIANCES 1 FLOORS-6 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 R C I V E
OVEN �. ._.. 3/G �r
POOL HEATER JUL 1$ 2)19
ROOM/SPACE HEATER �`
ROOF TOP UNIT •
aui Diwc . rr�nR`YXA �/
TEST Bv.
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
•
INSURANCE COVERAGE
I have a current liability_insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES R1110 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
- LIABILITY INSURANCE POLICY L� 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 perforated under the permit issued for this application will be in complian all Pertinent vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#1 1 9 7 7
SIGNATUR
MP VMGF❑ JP❑ JGF❑ LPG!❑ CORPORATION Er# PARTNERSHIP❑# LLC 0#
COMPANY NAME C A-,0e &d nuo,hi Al At2Rei ADDRESS L- 0. ebcX gal
CITY SQ t/?It De,./4/ t S STATE M4- ZIP 0 Z 6 6 b TEL So 1— 311 -Z Z ZcP
FAX CELL EMAIL C q Joe OscY p1v076ta f (9,y4400 . 6.,
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