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Home My WebLink AboutBldp-19-005501 = mASSACHUSETTS UNIFORM kk, APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK --_ CITY �k vJi �G MA DATE: PERMIT#&a795 � JOBSITE ADDRESS S � (�c� _ 'OWNER'S NAME ___. . ... OWNER ADDRESS stet A-6c kr� Cal a�`.�� G rni TYPE OR TEL o�_ � 8 q FAX � OCCUPANCY COMMERCIAL CLEARLY TYPE EDUCATIONAL RESIDENTIAL NEW: / RENOVATION: APPLIANCES i FLOORS-, REPLACEMENT: PLANS SUBMITTED: YES BOILER �0© Q©vw NO r � BOOSTER ��®®��0®®� CONVERSION BURNER a■■■� ®® ®®�� COOK STOVE �� ®��® DIRECT VENT HEATER ®® � ®® �� ®� 1.111 DRYER ® � �� FURNACEIMINIIIIIIIIIIIIMMINIMMINNIMINNIIIMINIMINI ® ®� nallalrilal GENERATOR �� INFRARED HEATER ®�� LABORATORY COCKS �®® ��®��®® MAKEUP AIR UNITNIMMININIIIIIIIIIIMIMINIMINIMINNIMMININIIIIIIIIIIIIIMINIMM OVENalliiMiliniiiiiiianaiiiallinillaftaiiniaiiiii POOL HEATER �� : 4JTHEATER �� .ttillailklikiVIIIIIIIIIIIII �� ® � �., � UNVENTED ROOM HEATER ligiIme®®�a WATER HEARER ®�� ► + R � OTHER amommeammummeamonmeminuamidamammamame IIMININIIIIIMMINIMINIINIMINININIMMINININIMMININIIIIIMIN MIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIMMININIMINIMINMIII I have a current is ilk insurance policy or its substantial eqINSURANCE COVERAGEINI nt which meets I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVER THE E BY CHECKING the requirements of MGL.Ch,142 YES ✓NO LIABILITY INSURANCE POLICY i APPROPRIATE BOX BELOW OWNEROWNER'S INSURANCE WAIVER:I am aware that the licensee does noOTHER TYPE INDEMNITY BOND I 'S General Laws,and thaam signature on this PP my —mlt apaha_ve the Insurance coverage required by Chapter 142 of the permit application waives this requirement. SIGNATURE OF OWNER OR AGENT herthateby certify that all of the details and Information I have submitted or entered regarding thisapplication CHECK ONE ONLY: OWNER AGENT nd eby all e plumbing work t and tails l nd in performed under the lassachusetts State permit Issued for this app►�agilll be n compl compliance with withuall accurate jne�b�oof v'smy knowledge Plumbing Code and Chapter performed of thee General Laws, LUMBER-GASFITTER NAME; provision of the fir Wade LICENSE# JP `�� SIGNATURE P MGF / JGF LPGI CORPORATION # )MPANY NAME PARTNERSHIP # Co DDRESS X STATE;(� 21Pf GZ�, CELL S t; `EMAIL; j n q� TEL, J1$ y l