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HomeMy WebLinkAboutBLDG-23-9565 � = MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK " : ram' MA DATE I 7� 3 PERMIT# LSD:�C:- z 3 -- 9 3`6,' JOBSITE ADDRESS G OWNER'S NAME - GWNER ADDRESS TYPE OR TEL FAX T CLEARLY OCCUP.A!'CY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW:❑ RENOVATION!: ❑ REPLACEMENT: B" PLANS SUBMITTED: YES❑ NO❑ APPLIANCES -I FLOORS—‘ asA BOILER 0 0 ©®__ 9 BOOSTER _®amili ® 13 14 CONVERSION BURNER v COOK STOVE nava i� isignings. DIP,ECT'�%EI��T I-IEP,TER DRYER, ILITIllialiallillrilintill FIREPLACEFP,I'C?LATORsi aim 11,1ati_..i.al GENERATOR = _ ---- GRILLE El= -- LABC?PRED HEATERRY COCKSMN ill Illi In 1141111. , MN all IIIII all 1111 MN . MAKEUP AIR UNIT all 111111 POOL HEATER __=______- ROOF TOP UNIT . NM.91.I, ff. 0 —=_ UNIT HEATER � a - ini : _ =__ - LINVEIdTEDROOM HEATER =®=-ia-•- WATER HEATERMa 11111 all OlHEI; ....:.."111111111111111111111111111111.. C❑C .. •• .." =1 vv.. C_C_ I have a current li INSURANCE COVERAGEv-_- abtls insurance policy !y y or its substantial equivalent which meets the requirements of MGL.Ch.142 YES V NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW El LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage re uired ❑ by rIClyapfier 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. t . k. 's\ SIGNATURE OF OWNER OP,AGENT CHECKONE ONLY: OWNER '�;; I hereby certify that all of the details and information I have submitted or entered regarding this application ❑ AGENT ❑ and that all plumbing work and installations performed under the permit issued for this application will be in compliance Massachusetts State Plumbing Code and Chapter 142 of theP are true and accurate to the best of my knowledge �`4 General Laws. with all Pertinent rovision of the PLUMBER-GASFITTER NAME .�are�- ,E ck C � LICENSE# f MP IS MGF❑ JP ❑ JGF❑ LPGI z ( R SIG ATURE ❑ CORPORATION[�# PAR a COMPANYNAMETIV r ,SHIP❑# LLC El�I € ADDRESS 7y in !6 5kt 62ea CITY 5'�' ti �kr o . � r�� FAX CELL � G., ZIP (G 2 �E G� TEL�37 ? CELL !L EMAILic,VF� �•1 � kr 5-03 ai(.CoF17