HomeMy WebLinkAboutBLDG-23-8790 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMITTI Ili TO PERFORM GAS•ITTING WORK
«. CITY J •• I MA DATE ACM PERMIT#$L OC—23—TM
JOBSITE ADDRESS G . * I ,/V �A r *WI ER'S NAME r �rlf�/'�
01M4ERADDRESS �
TYPE OR TEL FAX
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
CLEAFLY,Y NEW:❑ RENOVATION:0 REPLACEMENT:0
PLANS SUBMITTED:YES 0 NO D
APPLIANCES FLOORS—. HEM 1
BOILER NM --�NM
? 9 10 11 12 13 14
BOOSTER M111111111111
CONVERSION BURNER
STOVE 'B- w
DIRECT VENT HEATERME
DRYER — —_
MOM 11111.1111
FURNACEA
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OR111111111111111111111111111111111111N 1�
GRI LETOR . 11�M =II
LABORATORY COCKS . . o -
EDEZIONI MINIM POOOVEL = __
POOL HEATER __ ==
ROOM(SPACE HEATER _�M_
ROOF TOP UNITEn _-
UNIT HEATERIONIMMINOMMIIIIII IMI �=
IIIIII
UNVENTED ROOM HEATER MN MINIM
OTHER � _ _—. �-
111.111111.11.11111.1111111111...11101111 01111--__ IIIIIIIIII
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I have a current Iiabili insurance policy or its substantial 111111
INSURANCE
quiva ent which COVERAGE
the requirements of MGL.Ch.142 YESNO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW ❑
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
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.
ti SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and urate 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 th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBE ASFI ME LICENSE#
lQQ SIGNATURE
MP MGF J�GF(j�LPGI❑ CORPORATION❑# PARTNERS IP❑# LLC #
COMPANY �/Ef 0�I7�-J/l/<T I f-H /p�ADDRESS�?/ L I ON
CITY NA/T t/tI Ti 99STATE Hdle ZIP 0 e / 3 TEL
FAX CELL 5W5EMAIL if /1/r e 1 Milros
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