HomeMy WebLinkAboutBLDG-19-004014 ='_ Pt� SS C€6C15ETTS UNIFORM APPLICATION FOR APEF2ErllFT TOPE PERFORM GAS FITTING WORK
`: su CITY 1`11Z4- G✓'T7/ MA DATE //5 b PERMIT# G if? f'e'o y 0/y
JOBSITE ADDRESS 29 GJi.✓t2iu fr fixed{ ,E'p OWNER'S NAME,g,,, 4dy C-ZedSL 4,7
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OWNER ADDRESS Z g L.f.- p,o f X%-e_W L ‘I? TEL IDA:-?L c-5'ss/ FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑
PRINT
RESIDE
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CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑
APPLIANCES-1 FLOORS--h BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 ?
BOILER __I
BOOSTER
CONVERSION BURNER ,
COOK STOVE —__, I
DIRECT VENT HEATER '�
DRYER — _____1
FIREPLACE
FRYC)LATOR
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER j
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LABORATORY COCKS ?
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER I j
WATER HEATER I j
OTHER
Q�EVY c,.a--t-
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 COVVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY e- 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
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Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
',I•, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe ' nt provision of the
Massachusetts State Plumbing Code and Chapter• 142 of the General Laws. f
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PLUMBER-GASFITTER NAME LICENSE# Z y 74, SIGNATURE
MP ❑ MGF❑ JP - JGF❑ LPG' ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑#>
COMPANY NAME Yo. IL'c /j/1 EZi r7ty:cal-? 2 Pc-Ailm:i ADDRESS /((, L /L e i Li-t/v,✓E-- ICJ-,
CITY g,Ley..srZ-yam STATE /Ii1,d. ZIP 02C ` i TEL "?Z z ,DMZ 7
FAX CELL EMAIL )A K. LA, s r4-tf.-c 1.e 5.A..y.\, . c-.+.ti
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