HomeMy WebLinkAboutBLDG-23-9782 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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e CITY
MA DATE PERMIT L Z3 578L
JOESITE ADDRESS 9 (.t]iJY�n fu OWNER'S NAME "7'7
OWNER ADDRESS r'tr ro J\ p.1 TEL q 25G S o7 ---
TYPE OR PRINTOCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO
APPLIANCES 7 FLOORS—. SSM 1 2 3 4 5 6 7 8 s l0 11 r 1;
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR , _
FURNACE i" �+
GENERATOR
GRILLE DEC
INFRARED HEATER
LABORATORY i vd4d -
COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST -
UNIT i.
HEATER
(INVENTED ROOM HEATER
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 121 NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 4 OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I ant aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Generalj�Laws,and that my signature on this permit application waives this requirement.
„Wit CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and 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-GASFITTERNAME t L✓ :.JUf LICENSE# , 7 SIGNATURE
MP❑ MGF❑ JP® JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME`�� Alf Y� 1 A/G)44 }y ,n ADDRESS lag CYO lo-v'rn L11 L` /
CITY C.c,D',{wYN STATE\J /f)l) ZIP ( q TEL — D 1 L 77
FAX CELL EMAIL /)7f ✓GIYJ I?ILsSbl g e Gu1tA1.cam
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