HomeMy WebLinkAboutBLDG-23-9369 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
A —J� CITY ?
% �' MA DATE 7 I c; 2-3
JOBSITE ADDRESS 30 �, PERMIT# % -Z�..y36
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OWNER'S NAME I—I ie f,
G OWNER ADDRESS
TYPE C+ OR • TEL FAX
Yr a
CLEARLY
OCCUPANCY TYPE COMMERCIAL
❑ EDUCATIONAL ❑ RESIDENTIAL
NEW:❑ RENOVATION: REPLACEMENT: P
APPLIANCES PLANS SUBMITTED: YES 0 NO V
BOILER FLOORS 111111111111plimmini19 BOOSTER II I3CONVERSIOIV BURNEP,
COOK STOVE -
DIRECT VENT HEATEREll nil -
DRYER lar_l_islr..1
--
F
IREPLACEFP,I'CiLATOR Irim moram,
GE GRILLE --_ -
INFRARED HEATER - -
- ._1
LABORATORY COCKSEll all NO 111111.1111111111111 i
-�
MAKEUP AIR UNIT MIN MINI
POOL HEATER =-
ROOFf/SPACE HEATER
ROOF TOP UNIT _
llIll n...m1111111 .......m.111.11111111111.11111111111 IIM
UNIT HEATERNIMIIIIIIINIIIIIIIIII—®-11111111 ®-
INVENTED ROOM HEATER
OTHER nil
WATER HEATER Kill MIN -= MINI
I have a current INSURANCE rreayt laabili insurance policy or its substantial COVERAGE �-
cY
quivalent which
I IF YOU CHECKED YES PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKINGm THE
the requirements of MGl Gh.12 YES ,—,/`D ❑
•
LIABILITY INSURANCE POLICY � TI IE APPROPRIATE BOX BELOW �'J �
OTHER
' OWNER'S INSURANCE WAIVED: I an,aware that the licensee does notha ethe TYPE
insurance
El BOND El
coverage required by Chapter 142of the
Massachusetts General Laws,and that my signature on this permit application waives this
. 715 requirement.
'`� SIGNATURE OF OWNER OR AGENT
CHECK ONE ONLY: OWNER
=.1:• I hereby certify that all of the details and information I have submitted or entered regardingthis ❑ AGENT
and that all plcertify
that
work performed
9 and intallationst undere the permit issued for this application will be in compli nce with all Pertinent and hasetu Stang Plumbingwork
Code application are true and with all eo in the best of my ;
and Chapter 142 of the knowledge
LEI
PLUMBER-GASFITTER NAME general Laws, it provision of the
LICEIJSE#ii ,��,� ��
MP v1C;F❑ JP❑ JGF❑ LPG! ❑ CORP `-16 SIGNATURE
COMPANY NAME 31m CORPORATION[] !F PARTNERSHIP 0#
l f LLC
CITY r c l lr. ADDRESS / r . A '
FAX STATE ^Ln. q__ ZIP �`7 Z 6 i ;�.
CELL 7 7� TEL
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