HomeMy WebLinkAboutBLDG-19-000241 /o /2 ell= w x,„
MASSACHUSETTS UNIFORM APPLICATION FOR A PERM O PERFORM GAS FITTING WORK
,.eo CITY YCjie"iIhc-r ti^ I DATE 7 LL /.�tC PERMIT# 5 /7 o of
JOBSITE ADDRESS -7 T)r ( err, OWNER'S NAME Roes
OVVNER ADDRESS TEL 61r1-�7J
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL PRINT ❑ RESIDEWTIAL��
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:2 PLANS SUBMITTED:YES 0 NO❑
APPLIANCES 7 FLOORS 6S1d 1 2 3 4 5 F 7 8 9 10 11 12 13 1E
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER —�
DRYER —�
FIREPLACE
FRYOLATOR
FURNACE -
GENERATOR.
GRILLE
INFRARED HEATER
LABORATORY COCKS —�
MAKEUP AIR UNIT r
OVEN )Y
POOL HEATER
J _
ROOM 1 SPACE HEATER
ROOF TOP UNIT
TEST .. • _ .
UNIT HEATER
UNVENTED ROOM HEATER I —
WATER HEATER I OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent wh'h 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 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.
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 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
Li) Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GAS ER NAME LICENSE#Js)y SIGNATURE
MP MGF❑ JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTN P❑# LLC❑#
COMPANY NAME Vey%Kb�, ��'7 ADDRESS ��O �/4 ��/�i
CITY 'I`1 0 144 STA f) ZIP TEL�C�
FAX l CELL SJ S 7/, 7I J, EMAIL L/e/'lrf'e�01 frivi) ,/ice,
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