HomeMy WebLinkAboutBLDG-23-9690 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOESITE ADDRESS__ ��n d
G OWNER'S NAME .✓a,!` (Liff`cLv
OWNER ADDRESS
TYPE O; TEL S� .�Pd FAX
TF E O OCCUPANCY TYPE COMMERCIAL 15�
CLEARLY ❑ EDUCATIONAL ❑ RESIDENTIAL�.�
NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑
PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES t FLOORS-H. SSl 1 7
BOILER - 5 s 9 to ®® 13 1,,
BOOSTER ( p--
CONVERSIONs,.
BURNER
COOK STOVE -
DIRECT VENT HEATERall11111DRYER
FIREPLACE —C —
FURNACEFRYOLATOR
bill
GENERATOR _---
GRILLEIllinallm___________
—
INFRARED HEATER -
LABORATORY COCKS MA
KEUP AIR UNITEOVEN
—
POOL —
POGLHEATER ----
ROOF ;SPA.CE HEATER —MME11.1111
ROGF TOP UNIT
TEST -
UNIT HEATER . .__ . .
UNVENTED ROOM HEATER u— �—
WATER HEATER � —
OTHER
MMINIIII
-MIN IL O I N G U E PA Rl"i ,—
INSURANCE COVERAGE '�"",�-
I have a current liabili insurance policy or its substantial equivalent vehich meets the requirements of MGL,Ch.1 42
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW YES ❑ NO ❑
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
1• 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 waive;this requirement.
.
'� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑
\I; I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate
and that all plumbing work and installations performed under the permit issued for this application will be in c pliant ith all rt'
Li j
Massachusetts State Plumbing Code and Chapter*142 of the General Laws. to the best of my knowledge
meat{?ro si `'of the
PLUMBER-GASFITTER NAME /fTU .
LICENSE#��M SIGNATURE
MP ❑ MGF❑ JP ❑ JGF❑ LPGI l;
COMPANY NAME / �/ 'ORPGP�1TIOIV❑# PARTNERSHIP El�r LLC #
!/ ❑
CITY &Ile
ADDRESS
FAX STATF,/f9 ZIP z' ei _ TEL Sal'A3?•Serr
CELL EMAIASP 1�//i A005
dMi)67- �° 5� fie.-,,�