HomeMy WebLinkAboutBLDG-17-001315 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ey; CITY V)7Y2MCk) ?1? MA DATE //, 'sr � l[l /PERMIT#/We'—/7—Glf% /r
JOBSITE ADDRESS-5/j iej J iStL-z.Z t1 OWNER'S NAME 11 eg P0
GOWNER ADDRESS )emu TEL 7 Y/4 29 \ Z/Z/ FAX
TYPRINTPPR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL(
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7 FLOORS 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
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
17 Il 12.61 uoA)
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalenjt which meets the requirements of MGL.Ch.142 YES INt NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laval,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
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 performed under the permit issued for this application will be in comphan with all Pent ro ' n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME'A,/lederti l Tf/�Y� ' LICENSE# 1/ / SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPGI[,1r CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME �) t )2i) /12/ €4VC ADDRESS Ro ' 12
CITY 5 - STATE Al4 ZIP al TEL ,33a `>Z,'2) )2-
FAX 7Zd 33 CELL 10'9-12 `f V EMAIL
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