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HomeMy WebLinkAboutBLDG-20-002800 -r. MASSACHUSETTS NIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �, rMOtet MA DATE JOB E ADDRESS /03 9/01 i C.e--1/°(' OWNERS NA OWNER ADDRESS TEL7 /?3C//Q FAX • TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL PRINT ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: / PLANS SUBMITTED: YES© NO lEe- APPLIANCES-1 FLOORS-4 BSMul 1 2 3 .1 5 6 7 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE - ---17 DIRECT VENT HEATER DRYER FIREPLACE [ r i FRYOLATOR FURNACE GENERATOR _ _] GRILLE ' f _1INFRARED HEATER '; .. LABORATORY COCKS _ ------11 f, —_1 MAKEUP AIR UNIT OVEN N 1 d M9 - POOL HEATER _ ROOM/SPACE HEATER • [ t3'-t�:, -iz ,, -y- T — ROOF TOP UNIT I ''y ----4------1 _ _-_ L......, ----- TEST UNIT HEATER Ut4VENTED ROOM HEATER WATER HEATER _� J OTHER I�'' I INSURANCE I have a current liability insurance policy or its substantial equivalent COVERAGE ent which meets the requirements of MGL.Ch.142 YES 0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY j 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. • CHECK ONE ONLY: OWNER ❑ AGENT ElSIGNATURE OF OWNER.OR AGENT '' , I hereby certify that all of the details and information I have submitted or entered regarding this application are true a accurate to the best - `- and that all plumbing work and installations performed under the permit issued for this application will be in compile c with all Pe inent • i y h edge Li j Massachusetts State Plumbing Code and Chapter.142 of the Gener Laws. p f the PLUMBER-GASFITTER NAME VM/2 6-0 (--ey��/ LICENSE#/�g SIGN TUP !�MP MGF❑ J ❑ JGF❑ LPG! ❑ CORPORA ION # PARTNERSHIP❑# LLC COMPANY NAME!' I, � ��,,//v II/-- � /�� f �./C(_4 l//)9 / DRESS y�/ (/?'I 7j /11e/X1_ r / ��r'c i j' n CITY ��/ STAT ZIP i), � CO �" TEL 7 2o .5 r) FAX CELLJ7/7 S? EMAIL LA (al 40- 4-go- ..._ 1 1 I I ,... II ,,, 4 1 L I i f7 1 I Z o c �o 0 t..uc U L1.1 W = w I.. • < �. . C4 w w � w Ea a - Q d v • 0 EL < 69• Dr) UJ 1 P- Ull U_ , I 1 Iramr,, 1 M Z V U r} En 1 V I U , , , s