HomeMy WebLinkAboutBLDG-15-006456 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,' CITY ' 't` Kcti�c tU� 5c\Z.0 # MA DATE it 1 l _ PEi�IAIT#%G /�- �1 61/67v
JOSSITE ADDRESS _i _.1 I n e c1 r Z/Y-e- <1(t ,-)4„<-�. OWNER'S NAME TI L 1 L1 �i tV'�
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OWNER ADDRESS I '•TEI4 FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL:
CLEARLY NEW:r RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES!". N
APPLIANCES 1 FLOORS-, ISM 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 z to W
INFRARED HEA "-11' ` Z.(, a� =- I
LABORATORY ` t
MAKEUP AIR UNr
OVEN ,
POOL HEATER L.-
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER ` �.
0 ERI
'�1�C (;,'
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES P NO
I IF YOU CIECI®YES,PLEASE ItIBICATh THE TYPE OF COVERAGE BY CHECKING TIE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ER OT TYPE INDEMNiiY IT BOND
OWNER'S INSURANCE WAIVElt I am aware that the Manse*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 1_. 1 AGENT Li
SIGNATURE OF OWNER OR AGENT
I hereby cerSfy that all of the details and inromnadon I have submitted or entered regardng this application are to t of k edge
and that all plumbing work and motions performed under the permit issued for this appication wR be in nt the
Massachusetts State Pkmbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME I C !iCt S f?�! N-5-YI i UCUCENSE Si, 107057 SIGNA RE
MP ; MAGF JP= JGF s LPGI _ CORPORATION :#I 1 PARTNERSHIP`,# LLC #
COMPANY NAMEt ` P un b� o ADDRESS PD �j%X 35>i1
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CITY ( lit)e-8't-0a-4-it "J STATE; ILIA 21PI 62-tete d TB- - 77 ; ?l/= _:_
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