HomeMy WebLinkAboutBLDG-24-158 .= MASSACNUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
2 / 'Z/ ,/t l/='—' CITY W,'\ 1 MA DATE 3'$ 7 PERMIT i. =_
JOBSITE ADDRESS 73 Clecivay t tit l 4 DINNER'S NAME SE7+NG
OWNER ADDRESS ` 1 r
TEL 365:Yl FAX_______________
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL❑✓.'
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS
SUBMITTED: YES 0 NO❑
APPLIANCES-1 FLOORS BSM 1 2 3 4 5 !
BOILER n s 10 11 12 11t
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT'VENT HEATER �_
DRYER - _ �_
FIREPLACE
FRYOLATOR
FURNACE t/ ____________
GENERATOR
GRILLE
INFRARED HEATER _ _
LABORATORY COCKS
MAKEUP AIR UNIT '
OVEN
POOL HEATER -
ROOM I SPACE HEATER -
ROOF TOP UNIT
q
TEST - F�i, V F.
UNIT HEATER —INVENTED ROOM HEATER MAT v v LU2
WATER HEATER
OTHER
quit DiNG -I- R NENT
,ry
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES EINO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW El
LIABILITY INSURANCE POLICY Q"." 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,and that my signature on this permit application waives this requirement
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT 0
s::,Iz I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd accurate to t best of my knowledge
and that all plumbing work and installations performed undar the permit issued for this application will be in com ante with 1ILPe nt provision of the
LIJMassachusetts State Plumbing Code and Chapter 142 of the General Laws. //'
PLUMBER-GASFITTER NAME LICENSE it , /cS 1 SIG ATURE
MP❑ MGF❑ JP 0 JGF[Vf LPGI❑ CORPORATION❑# ^ PARTNERSHIP❑it LLC❑it
COMPANY NAME rtili'�r`tS " N 4 C. ADDRESS uC 64 '•-1 P. �j�-q >�CITY PV-(1',,C,LIP� STATE NAJ1- ZIP ��36Orn���[�TTELL 6 -75 °-46Q-
FAX CELL i- �1(� EMAIL✓QP�J644M6 11E/T4 C47. Co.2k.
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