HomeMy WebLinkAboutBLDG-17-005303 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
p CITY y.-'v—, a 7 n' MA DATE I--1 ii i--i /17 PERMIT# /X "'/-7-CV 3 5
JOBSITE ADDRESS 10 /1 i-J.-cc- S OWNERS NAME G-e- _ er,.
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[1-'''''"----
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:er PLANS SUBMITTED: YES❑ NO 0 1
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APPLIANCES -I FLOORS-4 BS1v1 1 ? 3 4 5 6 7 R 9 10 11 12 13 1
BOILER _____I
BOOSTER
I
CONVERSION BURNER I
COOK STOVE '
DIRECT VENT HEATER _
DRYER I I
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR.
GRILLE '
INFRARED HEATER I
LABORATORY COCKS •
MAKEUP AIR UNIT i
OVEN i
POOL HEATER y {
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST _
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER
OTHER
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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 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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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 ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT J
I hereby certify that all of the details and information 1 have submitted or entered regarding this application are true and accurate to the best of my knowledge I
`— 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
� Massachusetts State Plumbing Code and Chapter'1�42 of the General Laws. '
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PLUMBER-GASFITTER NAME c„P/&-r-,Se LICENSE#t30 � SIGNATURE
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MP ❑ MGF❑ JP [/1GF❑ LPGI ❑ CORPORATION❑4 PARTNERSHIP❑#� LLC❑#
COMPANY NAME f.n i sr i` f/cliri.4.•_�, ADDRESS (e 3 (Ar-,r;/1 , •? - -..
CITY 0.,. -4--c A, 1' STATE AG ZIP iSZ 6.7ST
FAX CELL S 9 Z Z'4-(00( EMAIL APR i 2011
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