HomeMy WebLinkAboutBLDG-17-005195 '�. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�� �� u b I'll— It Pb /7- t /yam` ,4-,;s CITY h4�, UATEPERMIT
JOBSITE ADDRESS 65 1-bncl TGtLtx..--) ‘ti r' OWNERS NAME ZOB C .0-(Z. _
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 4 FLOORS-+ BEM 1 2 3 4 5 6 7 8 9 10 11 12 '13 1'
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE i
FRYOLATOR
FURNACE
GENERATOR. _ j i o
GRILLE APR i
INFRARED HEATER I
LABORATORY COCKS — 1 i !
MAKEUP AIR UNIT 1
OVEN i
POOL HEATER
ROOM /SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER
OTHER
INSURANCE COVERAGE '
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY 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 Genera! Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑ li
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 ._- : y knowledge
`k- and that all plumbing work and installations performed under the permit issued for this application will be in jlian ail ' !•ant prov':ion of the
`' Massachusetts State PlumbingCode and Cha to 42 of t General Laws. I
P �
L} PLUMBER-GASFITTER NAME 'JJ�. 'e LICENSE# f.S2•GC) �� ' SIGNATURE
MP ! `�o� t�MGF❑ �JP ❑ JGF❑ LPG' CORPORATION❑ F PARTNERSHIP❑# LLC ��Y
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COI PAIRICI I�I I�IN"
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CITY (kr�ltA„ STATE 10 n ZIP O�1J L, TEL 5 V 0-�3."-r T I
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