HomeMy WebLinkAboutBLDG-20-000995 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`. ,s" CITY p tt All V-c!r �C'� r r MA DATE PERMIT#/JLAG�O�� �
JOBSITE ADDRESS //• ,4/2/4 d toh44''' • D t. OWNER'S NAME N- •rifv 0
GOWNER ADDRESS /1• fin I C} �-2/11-77,A D TEL bri3�' '�r '•08 Y
TYPE OR TYPE
--yA AA O ti rit-pd
PRINT T COMVERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Il
CLEARLY NEW: RENOVATION: 0 REPLACEMENT: El PLANS SUBMITTED: YES
APPLIANCES 1 FLOORS-4 BSM 1 ? 3 1 5 6 7 6 9 10 11 12 *13 14
BOILER
BOOSTER F g ®�
CONVERSION BURNER ---t�
COOK STOVE
DIRECT VENT HEATER9 MI
DRYER �--
FIREPLACE ' ( BU �11 1'M=N.
FRYOLATOR =
FURNACE
GENERATOR.
el GRILLE --'
INFRARED HEATER 1
A. LABORATORY COCKS I
MAKEUP AIR UNIT j
OVEN I
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
II TEST
UNIT HEATER
s UNVENTED ROOM HEATER 1
WATER HEATER
OTHER
4.
---1
40
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L"J NO ❑
it I IF YOU CHECKED YES,PLEASE.INDICATE THE TYPE OF COVE yE 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
VII Massachusetts General Laws,and that my signature on this permit application waives this requirement.
i 11
Y' CHECK ONE ONLY: OWNER ['I AGENT ❑
�` SIGNATURE OF ' NEP.OR AGENT j
' -• I he . y 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 I
`- and that all plumbing work and installations performed under the permit issued for this application will be in compli.• e with all Pertinent p vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LJ Ilia6
PLUMBER-GASFITTER NAME LICENSE#,2a3ICj SIG T I.RE
MP ❑ MGF❑ JP Ld JGF❑ LPG' ❑ CORPORATION❑tF PARTNERSHIP❑# LLC❑
COMPANY NAME Zr(-- /t'_39' ADDRESS�TX.1Vv__c_ �.okik/ �O
CITY J cCA.)1 'L� n t
STATE WII. _ ZIP 0 3-5-6 -1-) TEL
FAX CELL 50y?(pa-5p(c(EMAIL
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