HomeMy WebLinkAboutBLDG-20-002828 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
t= " CITY (,J 51 Y://2497/ f7 4" MA DATE /0 9 /i 9 PERMIT# i3Lo6'olfl-OOSAS
JOBSITE ADDRESS /03 Lca . )/y / OWNER'S NAME y
G OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑PRINT RESIDENTIAL[� ''oD
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: [ PLANS SUBMITTED: YES❑ NO 2'
APPLIANCES Z 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 r`_ -T
POOL HEATER • �' r r .
ROOM!SPACE HEATER -
ROOF TOP UNIT `
TEST s 4 2'319 li
UNIT HEATER •
UNVENTED ROOM HEATER F � '
WATER HEATER W--
OTHER 1 v
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 24 ❑
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 performed under the permit issued for this application will be in comp) wit Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 3 f ..4 A,[ ,W[& 2 is LICENSE# /!177 SIGNATURE
MP"MGF❑ JP❑ JGF❑ LPGI'❑ CORPORATION 2( PARTNERSHIP❑# LLC❑#
COMPANY NAME C (d /1 hd, ,,1 f }-hdl At1 -14/C ADDRESS PO 45 axtitc
CITY Sod?( /&v4/i J STATE f'V ZIP D Z 6 0 TEL 5b -J Iv -ZZ
FAX CELL EMAIL
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