HomeMy WebLinkAboutBLDG-18-002563 J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
r CITY Yitallt aO W 8 Dor MA DATE /d/3// 7 PERMIT#AJ)fj /('410 0
JOBSITE ADDRESS I 4 E1 L- _ _ ' 5 t' OWNER'S NAME L//f MAW
GOWNER ADDRESS A.1 i TEL q/3 qv J 3e- FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL( ,K'
PRINT
CLEARLY NEW:0 RENOVATION:Rti REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO•[
APPLIANCES'1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13
BOILER - -
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER .
DRYER
FIREPLACE •
FRYOLATOR - - '
FURNACE
GENERATOR .
GRILLE
_INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT d
OVEND
•POOL HEATER
ROOM I SPACE HEATER ti fril.ir,;s
ROOF TOP UNIT _
TEST ✓ .
UNIT HEATER
• UNVENTED ROOM HEATER
WATER HEATER
OTHER 1e
/4) L A 7 Ft/xs _ i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equlvaierlt which meets the requirements of MGL.Ch.142 YESNO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0- 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
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 knowled
and that all plumbing work and installations performed under the permit issued for this application will be in m Hance with al P ' e provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME MUM&Z C•4 Fcgl-->4-0-1-- LICENSE#//J!ii SIGNATURE
MP 0 MGF 0 JP 0 JGF❑ LPG, CORPORATION El# PARTNERSHIP 0# LLC❑#
COMPANY NAME I-14 5' Z_.II0 PDc1p il.n i g• ADDRESS g a, igdk l 20 7
CITY S• "/UN/ STATEI4A' ZIP Od 6 4,2 TEL S3 erg 4 D z -2 7
FAX 7 G' [ / '3 CELL �Q 2,S- 1-7 9 V EMAIL '
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