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HomeMy WebLinkAboutBLDG-23-9444 -- . _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE Zc JOBSITE ADDRESS 7o e Lei yy� GOWNER'S NAME Ke 0 ''. C(k h, OWNER ADDRESS TEL 7b(-8l 2 -SS TYPE OR FAY PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL [t]----- NEW:❑ RENOVATION: ❑ REPLACEMENT: 11--- PLANS SUBMITTED: YES 1 NO E APPLIANCES T FLOORS-f BSM 1 a BOILER ® oIMMINEMER BOOSTER 13 14 CONVERSION BURNER COOK STOVE DIRECT VENT HEATER - DRYER FIREPLACE FRYOLATOR FURNACE ...I GENERATOR GRILLE INFRARED HEATER • �.. - LABORATORY COCKS rr 1 v �- -- --- MAKEUP AIR UNIT -- OVEN ,Y POOL HEATEIIIMMINIMMI ROOM/SPACE HEATER ROOF TOP UNIT t SING UEF'ARTna - TEST nr _Mil — UNIT HEATER LIPJVEh1TED ROOM HEATER —, iNATER HEATER L OTHER —__ ..0 INSUGE I have a current liafaili insurance policy or its substantial equivalent which NCE OVmee s the requirements of MGL.Ch.142 YES I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW © ❑ LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND El 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. C. .`r ••• SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ '1;; 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 corn 'ante wi h all Pe ' ent P isi ro ' 1,14 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. on of the PLUMBER-GASFITTER NAME LICENSE SIGNATURE MP� MGF JP l� �,GS' ❑ JGF❑ LPGI ❑ CORPORATION❑# 1 COMPANY NAME Vh1.rc. cir,icl PARTNERSHIP I�� LLC❑# ADDRESS 36 v2Q vt )411 n STATE ✓r1 �t- ZIP es Z6``$ SE c� FAX CELL TEL'-��� Z 1C� �j'___L EMAIL Ybt:cl- etf()Q. Ole( ha(1:ci 1 @ c I 1 G1 tJ I;-4 V 0 J I P I NirIc ▪ 60 -a N I 4 f7 1 i `J 1 I \ . i I ,-, 0 E i I ,,,-1 2 � I cap 1-- a iA con ...,1i .. < LU G� CO Q Iz - � u.1 G.1 co - Q �, pa I— Cri v Fil --i • Q. < ee cn Li I E Lit I— w (—I 0 1 7 H I 0 I co I cr./ 0 I4 1 i