HomeMy WebLinkAboutBLDG-18-005255 "I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`` t_-R CITY JUvTIf MA DATE 3 /q - 2- /O PERMIT# I,6/7-00 J`vrJ
JOBSITE ADDRESS 3 Y 1. JGg/it—ICi?)0 pe. OWNERS NAME // "Ht l 7? AJ
GOWNER ADDRESS TEL FAX
PE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Eg'
PRINT
CLEARLY NEW:[( RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-I FLOORS--F BSIui 1 ? 3 4 5 5 7l_ 8 9 10 �11 12 13 14 I
BOILER _______I
BOOSTER
CONVERSION BURNER i
COOK STOVE
I
DIRECT VENT HEATER
DRYER — I
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER �_ ,) i
LABORATORY COCKS ` _ i
MAKEUP AIR UNIT
OVEN
POOL HEATER —.,
ROOM I SPACE HEATER
ROOF TOP UNIT �,
TEST . . ��
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER I I
.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1/14Q ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ I
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
tMassachusetts General Laws,and that my signature on this permit application waives this requirement.
•l CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
,-1-• 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 I, owledge
`-- and that all plumbing work and installations performed under the permit issued for this application will be in compliance •h all P • tt vision 3t -3e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LE IPLUMBER-GASFITTER NAME /J4yNc 02/M PS LICENSE# 3/.Ssf'i GNATURE
MP ❑ MGF❑ JP [ JGF❑ LPG! ❑ CORPORATION❑4 PARTNERSHIP❑# LLC❑#l: I
COMPANY NAME 02
witgas Ple t4 ADDRESS 24 6 i,'T onl& G
CITY JAW ( / ,-174 STATE M0 ZIP 6L40'73 TEL 27 Li- S36- 2S3 Li 1
FAX CELL EMAIL W+i-`'l. t; Leu...:frti3l10 Go4/1/t . Ecsvi
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