HomeMy WebLinkAboutBLDG-23-9414 = MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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-';� ling, DATE PERMIT# LU< G S 9`//G
JGESITE,ADDRESS
///r"�(/_3✓ Z'0✓i OWNERS NAME � 'e'n -e
G OWNER ADDRESS 5,9-'7 e TEL
FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL HUNT ❑ EDUCATIONAL ElRESIDENTIAL 3--
CLEARLY NEW:❑ RENOVATION:42 REPLACEMENT: ❑ PLANS SUBMITTED: YES
APPLIANCES FLOORS-+ B.M 1 2
3 1 5 6 7 ° 9 10 11 1 2 _I; 14
BOILER -
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYC)LATOR
1
FURNACE
GENERATOR
GRILLE J
INFRARED HEATER i
LABORATORY COCKS --�
MAKEUP AIR UNITI
OVEN ----1
POOL HEATER
ROOM/SPACE HEATER --
ROOF TOP UNIT
TEST - . } . 1
UNIT HEATER
��
UNVENTED ROOM HEATER _
WATER HEATER 1
OTHER
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INSURANCE COVERAGE l
I have a current lial___ALkinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ElyNO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er OTHER TYPE INDEMNITY ❑ BOND ❑
• OWNER'S INSURANCE WAIVER: I era 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 valves this requirement.
SIGNATURE OF OWNER OP,AGENTCHECK ONE ONLY: OWNER C. 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 compliance w' all Pgrtinent provision of the
Massachusetts State Plumbing Code and Chapter•142 of the General Laws. /J
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PLUMBER-GASFITTER NAME
LICENSE#d0-_. l ATURE
MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑/� LLC 77
COMPANY NAME +9='`1t' 2j j ,
,// ADDRESS 3. �"v� t" �� C
CITY /"7r�,
STATE h-76' ZIP G V,_ TEL 77Y,31, - 3lG�
FAX CELL
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