HomeMy WebLinkAboutBLDG-19-000370 �-` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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C!T� MA DATE PERMIT#
JOBSITE ADDRESS OWNER'S NAME� -7 1^"4.6�9[[//-I((�!�' '7
OWNER ADDRESS 1' TEL 6 0—7j/
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL Ik/
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:L.1••••" PLANS SUBMITTED:YES 0 NO❑
APPLIANCES 7 FLOORS-, sit t 2 3 4 5 6 7 8 9 to 11 12 to 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE •
GENERATOR I —
GRILLE I —
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEA I EH y I i
UNVENTED ROOM HEATER
WATER HEATER
OTHER I I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO❑L.".
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND ❑- j 7 20113
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter f42 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement. ett,r790/7 1"(0:
CHECK ONE ONLY: OWNER 0 AGENT ❑ I
SIGNATURE OF OWNER OR AGENT
is I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc 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 II Pertinent provision of the
"" Massachusetts State Plumbing Code and Chapter1J� C
142 of theGeneral Laws.
PLUMBER-GASFITTER NAMETj o^ V Q U LICENSE#15:7' TORE
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0 CORPORATION 0# ARTNERSHIP❑# LLC 0#
COMPANY NAMEC .Q V QA7 ( ADDRESS /r.)•g-� 77 �j
CITY t Cuipi4 4 L STATE%, ZIP 02,7(-0- )C TEL 3y` 779(�7
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