HomeMy WebLinkAboutBLDG-20-002940 ' MASSAC USETTS UNIFORM APPLICATION FOR A P RNlIT TO PERFORM GAS FITTING ING WORK
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,w CITY /7 / / 9 l q TKO 1 DATE /( ( PERMIT# /y c______
JOBSITE ADDRESS .3 S—t4g'1'/5 0 L9 OWNER'S NAME J G C
GOWNER ADDRESS TEL�S TEL 2/?OD,c-7' FAX
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TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑
PLANS SUBMITTED: YES❑ NO 0
APPLIANCES FLOORS-+ BSM 1 2 3 1 5 6 7 6 9 10 11 12
BOILER 1J 1^.
BOOSTER
CONVERSION BURNER
COOK STOVE
III I
DIRECT VENT HEATER
DRYER
FIREPLACE —
FRYOLATOR �
FURNACE
GENERATOR
GRILLEI
INFRARED HEATER
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LABORATORY COCKS11 I
r.
MAKEUP AIR UNIT
OVEN
POOL HEATER t` {
ROOM I SPACE HEATER -
ROOF TOP UNIT
TEST -.. --- - -
UNIT HEATER
INVENTED ROOM HEATER
WATER HEATER / ____
OTHER
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INSURANCE COVERAGE —I
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g 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
Massechus-efts General Laws,and that my signature on this permit application waives this requirement.
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SIGNATURE OF OWNER OP,AGENT CHECK ONE ONLY: OWNER ❑ AGENT El
`l, 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 Pertinent provision of the
N'` Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME rk-- r' G40 LICENSE
SIGNATURE
MP❑ MGF❑ JP ® JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑41, Lc❑#
COMPANY NAME/ � C C, /O _O P�-- ADDRESS ' /7 6/577 C .Q C/
CITY W �( STATE 1^-Aik ZIP D 7 0 7 3 TEL 77 7( 2, Z2
FAX CELL EMAIL S -t.,-. + � Q
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