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HomeMy WebLinkAboutBLDG-19-002999 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ``„,•L iJ" CITY yil Rm.+ i 14 pse 1 MA DATE /j /7/j PERMIT# /.7 2t-`19 JOBSITE ADDRESS 3 2- eig uti,'Trrf u e gd OWNER'S NAME / MN ` _Vt1� G I Y - GWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL DU PRINT ❑ EDUCATIONAL ❑ RESIDENTIAL©-------_ CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [I.K---- PLANS SUBMITTED: YES❑ NO❑ I APPLIANCES 1 FLOORS- scitn 1 2 3 4 5 6 7 5 9 10 11 12 '13 1 BOILER _L_- _____I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER __I DRYER ____I I FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER I LABORATORY COCKS _ —" + ! MAKEUP AIR UNIT 1 - - ' . -E �, OVEN �j i POOL HEATER 1 ROOM I SPACE HEATER t ' ,10.114 ROOF TOP UNIT qr TEST I �`� ; �n`F TMEN T UNIT HEATER _ ' UNVENTED ROOM HEATER I WATER HEATER _� OTHER I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. i 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 ar t nd,acc st of my knowledge i and that all plumbing work and installations performed under the permit issued for this application will be i co rovision of the Massachusetts State Plumbing Code and Chapter'142 of the General Laws. ' LU G PLUMBER-GASFITTER NAME LICENSE t,'/! SIGNATURE MP ❑ MGF❑ JP ❑ JGF❑ LPGI E CORPORATION❑4Fj PA.RTNE .SHIP❑# LLC❑#> I COMPANY NAME ADDRESS /" adz/ '1/43 CITY S /47/amt,7 S 17c4c7 STATE 14 /e ZIP 0 24.0 7 2 TEL C c3 23 I/-6 to 9 FAX CELL EMAIL ,�Ss�/ 5 kJ i /,iG ; (' � i/ I i I vi Fb C I C) 1 41 Cr) I 4 a I a ❑ Z G 1,1 El cr.) 41 g 0 a 0 2r Z I W jcry en. _ r _ .... ... in_ En O �'" w uU_I ✓ cto - C9 -. A. Q i -7 • °- crs w ' s LU I I- U- 1 1 I 0 0 1 C) W ICID 1 C) I C.,1 0 i