HomeMy WebLinkAboutBldg-19-005624 ,`► � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT MIT TO PERFORM GAS FITTING WORK
tL. CITY Jo kerb- 4'4 `� ��f MA DATE ei /3/ �l PERMIT*1a6 5-62y
�� JOBSITE ADDRESS / d/C(/.7 ,Ai77 OWNERS NAME 6 r i hi /''o
GOWNER ADDRESS TEL FAY,
TYPE OROCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL 1?"--
HUNT
CL A_RLY
NEW:V RENOVATION: Ie/ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO ❑
APPLIANCES_i FLOORS-' BSM 1 2 3 1 5 6 7 3 9 10 'VI 12 1
BOILER I
BOOSTER ______I
I
CONVERSION BURNER _p,- • q i
COOK STOVE
DIRECT VENT HEATER ` : .„
DRYER c v- ,
FIREPLACE -7
Mil I
FRYOLATOR , t:
FURNACE I z `'� "-
GENERATOR. , xi o ha
GRILLE K' i
INFRARED HEATER z
LABORATORY COCKS Mom
MAKEUP AIR UNIT •
i
OVEN I i
POOL HEATER
1
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER
OTHER 1
1
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MOL.Ch.142 YES 4O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE`4 e E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L„fi 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 valves-this requirement.
. 1
CHECK ONE ONLY: OWNER ❑ AGENT ❑ i
SIGNATURE OF OWNER OR AGENT
i-s I hereby certify that all of the details and information I have submitted or entered regarding this application are true a ccurate to the best o y knowledge J
`- and that all plumbing work and installations performed under the permit issued for this application will be in corn c with all ertine - ision of
• Massachusetts State Plumbing Code and Chapter the G /
1
eneral Laws.
PLUMBER-GASFITTER NAME Da VI a v(/�' LICENSE# 4.33 o S—
SIGNATURE
MP E MGF❑ JP in--JGF❑ LPGI//P� ❑ CORPORATION❑# PARTNERSHIP❑/1 ,/ LLC y0#�/
COMPANY NAMEA V P l*/ ADDRESS /U/6 &vie .:/�f 6i/he Role
CITY p fr a.�G' • STATE ZIP U f)- 6 Y S TEL SO E- 6)-g7 01--6 y/7 I
FAX . CELL EMAIL U" ,, G/ f f Ot.,c, G ® G 14^c.//
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