HomeMy WebLinkAboutBLDG-20-001460 I ; ' _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
p W 61 CITY /'Wfrr,�ylf9/i /z1� # 0-413" -09/ 0
1�4r. DATE � � � PERMIT.�
JOESITE,ADDRESS 21 /4ij 11 / fld AUe OWNERS NAME 5),iv; h6rc1 e,"
OWNER ADDRESS TEL S A8-,5 �•iii FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[
PRINT
CLE A 'Y NEW:❑ REND\/ATION: ❑ REPLACEMENT: 113/ PLANS SUBMITTED: YES❑ NO❑
•
APPLIANCES 1 FLOORS—+ Bail 1 2 3 4 5 6 7 6 9 10 'I'I 12 •13 1
BOILER i{
BOOSTER ■
CONVERSION BURNER ■ _
COOK STOVE
DIRECT VENT HEATER
DRYER, ' I
FIREPLACE 1
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN ',. 'y I "
POOL HEATER
ROOM/SPACE HEATER
t
ROOF TOP UNIT i' 1
TEST _.- __
' ')- UNIT HEATER '
UNVENTED ROOM HEATER
,,� WATER HEATER -- .,, a'Vx / I
1 OTHER
I
v INSURANCE COVERAGE _-/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 Yet' ❑ ND D
-.4), I IP YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY / OTHER TYPE INDEMNITY ❑ BOND ❑ I
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
3 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
,, CHECK ONE ONLY: OWNER ❑ AGENT ❑
`.. SIGNATURE OF OWNER OR AGENT
.l.i 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 witp all Pertinent pt r iii of the
`I Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��!7 �, jj�2'/i
PLUMBER-GASFITTL-R NAME IA)a yi",& k1 kby LICENSE# /tS5 2,
✓SIGNATNF -''/
MP❑ MGF❑ JP❑ JGF❑ LPGI_t ❑ CORPORATION❑#F PARTNERSHIP❑#� LLC❑#F
COMPANY NAME e-, ' n�P,+-i 1^ r Ivyrr tc-- ADDRESS p /3 1 Cit< L'e°r i t e' �c
0e.n n a-$ STATES ZIP 6 z�3e TEL jb -Col9 —7 '1
CITY ,�
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