HomeMy WebLinkAboutBLDG-20-001194 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`"`_' ! vf7 MA DATE q 3 -G-�` a4 _� /`7
�. ,rts� CITY � Q.G�O PERMIT#Vim ; ,
JOBSITE ADDRESS SAY P pet OWNER'S NAME ievarr7
GOWNER ADDRESS 96 /v� i k'I11 P . TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL EV.
PRINT
CLEARLY NEW:❑ RENOVATION: V( REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
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APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 1•I 12 13 14
BOILER ____I
BOOSTER 1
CONVERSION BURNER I
COOK STOVEII
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1
DIRECT VENT HEATER
7 I
DRYER
FIREPLACE 1
FRYOLATOR '
FURNACE
GENERATOR I
GRILLE I
INFRARED HEATERI
LABORATORY COCKS
MAKEUP AIR UNIT
I
OVEN j
POOL HEATER J � - " �_C ��._ �-_ I
ROOM I SPACE HEATER _
ROOF TOP UNIT ❑ ■ Z --___. _.� �_.f..�
TEST _.. °._
UNIT HEATER AL 6 3 0 zu f C'
UNVENTED ROOM HEATER . _ ,
WATER HEATER ( = i"-uir-,G 6EPARTII)FNT 1
OTHER = L
1
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE IIkIDENIN{TY ❑ 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 ONE ONLY: OWNER ❑ AGENT ❑
`` SIGNATURE OF OWNER OR AGENT
•I-• 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 compliance with all Pertine rovision o"the
Massachusetts State Plumbing Code end Chapter-142 of the General Laws.
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PLUMBER-GASFITTER NAME frA$,_, /4pf LICENSE# 3j<,ff--( GNATURE
MP ❑ MGF❑ JP 2 -JGF❑ LPG'❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME li�A/4/ ' _5' P I4' ADDRESS 2 I 1✓72A, 4474.//
CITY vv` Y 2vtfj,-( STATE Ad ZIP m 73 TEL 77 - SSC.-2i (
FAX CELL EMAIL a/4 rr--'6 P�4-✓7e3 67 gie4,4rc ,
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