HomeMy WebLinkAboutBLDG-24-22 # B-4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 16 I �1 c.14eLlrt Or, L e - 6-(-1 OWNER'S NAME UC 1 -'t y(
GOWNER ADDRESS I6I froe—Vyt1,0_6-, 0r- ��^t't'�-Li TEL s2 i-d.'tb-9y98 FAX J
TYPE OR OCCUPANCY TYPE COMMERCIAL Ei EDUCATIONAL ❑ RESIDENTIAL❑
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CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
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ROOF TOP UNIT RECEIVFD
TEST f
UNIT HEATER
UNVENTED ROOM HEATER BAN 05 2024 1 i
WATER HEATER J
BUILDING L
DEPARTMENT
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES ❑ NO j
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
Massachusett , signature on this permit application waives this requirement.
w CHECK ONE ONLY: OWNER ❑ AGENT F
ATURE 0 NE OR NT
I hereby certify that all of the demos a ation 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ^ ���
PLUMBER-GASFITTER NAME Ju �r A '�' �-- LICENSE# 1p\ h(�-- SIGNATURE
MP ❑ MGF❑ JP RI JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC❑#
COMPANY NAME ADDRESS 14 S1„1 6o _. (Z,c- .a&
CITY vim.}-cA_0.`c STATE c Pr ZIP Oafo Li Li TEL 'SQL--...S I "'' -5-16
FAX CELL EMAIL J 5 7 . 0 LiCt o. (rjM