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Home My WebLink AboutBLDG-20-002352 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ir^_- -., "�� r CITY SDt)7/- ll✓Z{/7?Oii7fj MA DATE /O / I I 111 PERMIT#/,K06.�Q06."Z"0 JOBSITE ADDRESS q JZI Lt r Of-1 dL OWNER'S NAME kLnl • Att e_elkst h GOWNER ADDRESS - TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL C (©�' OU PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO[ ' 1 APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 I 6 7 8 9 10 11 12 I 13 14 i BOILER BOOSTER J CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE , - GENERATOR s I ` c- 0 I V . _GRILLE I F INFRARED HEATER a LABORATORY COCKS 1 I 01 %' 4 It)19 MAKEUP AIR UNIT i t 1 OVEN '. �, DIN• t �;.,, ,N, i 11 POOL HEATER =Y� ..._n=�--:_r- —._._ ROOM/SPACE HEATER ROOF TOP UNIT TEST - UNIT HEATER _ UNVENTED ROOM HEATER WATER HEATER OTHER I INSURANCE COVERAGE �� I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [ O ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 ONEONLY: 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 perfermed under the permit issued for this application will be in comp) with Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 3 r144j Hi bl rc1 LICENSE# 1077 SIGNATURE MP"MGF❑ JP❑ JGF❑ LPG! ❑ CORPORATION Pti PARTNERSHIP❑# LLC❑# COMPANY NAME C,4p1 ( d /T4/4141 1- i�v1 ?NG ADDRESS PO, r3 ax Litc CITY_S,tr✓�4 Awevi I I STATE PVV ZIP 0 Z 64 0 TEL 57 4' 'J?v -Z Z Z.J FAX CELL EMAIL i Lief/ C 4 q Ltt cc.) LL.