HomeMy WebLinkAboutBLDG-24-23 # B-5 K4111,411217;
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY U3eba- tiOtr h MA DATE 01103(2-y PERMIT# R L )e-Zt- z 3
JOBSITE ADDRESS Lff 1 P cX Tech. Ve. O r v - 6-3 OWNER'S NAME 0,IJ /'t 914
GOWNER ADDRESS (b 1 P h 4 Ttnuk C. TEL 'S( -9.`16.' 9998 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL IYr EDUCATIONAL ❑ RESIDENTIAL El
PRINT
CLEARLY NEW: El RENOVATION: ❑ REPLACEMENT: El PLANS SUBMITTED: YES El NO El
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
ROOF TOP UNIT
TEST I RECEIVED
UNIT HEATER
UNVENTED ROOM HEATER JA�1} 05 2O24
WATER HEATER
OTHER
t3U LDING DEPARTMENT
I uy --
I--
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES ❑ NO 11 '
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY El OTHER TYPE INDEMNITY El BOND El
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Gener- - •. that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT'441111111111111
TURE OF OW`' OR AGENT
I hereby certify tha - . -- : --- • 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 Pertinent provision of the
Massachusetts State Plumbing Code
and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME J Ll'n AraO cc`°/`e-- LICENSE# + SIGNATURE
MP❑ MGF El JP[f JGF❑ LPG! El CORPORATION El# PARTNERSHIP El# LLC❑#
COMPANY NAME ADDRESS t-t eck- kJ.
CITY f0ceSV .`e-- STATE`(Y,A ZIP Ob-coLick TEL cce -3S`18
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