HomeMy WebLinkAboutBLDG-23-9622 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ci*k.Ji IAA DATE 11/ /?-3
`�;���,s" CITY � vI. � -
n6v- PERMIT fr/�L j
JOBSITE ADDRESS 3 J e/'611 v aA, 1 fn.Y\L OWNER'S NAME �G
OWNER ADDRESS 3 J e, rs k TEL 1,;-A,v,e, TEL l -t'I 13 -® gS--o
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
❑ RRESIDENTIALP) T Efl
CLEARLY NEW:dj KENO\/ATION: ❑ REPLACEMENT: ❑
PLANS SUBMITTED: YES❑ NO KJ
APPLIANCES FLOORS—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 •I; 1,BOILER
BOOSTER
CONVERSION BURNER _________
COOK STOVE
DIRECT VENT HEATER
DRYER H
FIREPLACE
FRYOLATOR _
FURNACE ,
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER S _`� > v a
ROOM/SPACE HEATER ' NO 0 2 Ara
ROOF TOP UNIT
TEST ,
UNIT HEATER
• •---,4 iL.DI-NG DEFARTMEAJT
LINVENTED ROOM HEATER t
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ❑'NO [)
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ 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,ar that m ,mature on this permit t appii tiot4aives this requirement.
•
,y CHECK ONE ONLY: OWNER ❑ AGENT E
SIGNATURE OF OWNER OR AGENT
�:l•• 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 with all P rtinent provis' of the
'`'- Massachusetts State Plumbing Code and Chapter'142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP 2 MGF❑ JP 14 JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP❑# LLC 0
COMPANY NAME DGi✓'JG..1D Co 6+i VC+ on ADDRESS 155 e T C/ia)✓c, 5 1'
CITY �l ``>(-""i‘O STATE' !A ZIP OZ Lt V i.
TEL .S Og— 61 k`(7)N 76kel-
FAX CELL EMAIL iJct.r40-'�3 rov c G am,, t V(O V