HomeMy WebLinkAboutBLDG-19-002825 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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` -,1.__-s, CITY MA DATE 11 1�9 I t e, PERMIT# ��'C p($v'Z,
JOBSIT ADDRESS lc- 1/017•,f DcQ,A,ma 9 0( OWNERS NAME% T , Q Stet
GOWNER ADDRESS r4^ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIA
PRINT
CLEARLY NEW ' RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO are
APPLIANCES 1 FLOORS-4 BSM 1 2 3 1 5 6 7 5 9 10 11 12 •13 1
BOILER.
BOOSTER ______I
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CONVERSION BURNER
COOK STOVE
I
DIRECT VENT HEATER
DRYER
FIREPLACE —, i
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER W '_, __�
LABORATORY COCKS .._ '
OMVENUP AIR UNIT i 1 18
POOL HEATER i
ROOM I SPACE HEATER 1_-... _. _ .J !
1 RTM_J( i
ROOF TOP UNIT 1 #LG ._
TEST 7 i '_r'.__—
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER !
OTHER II I�1
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES IFIINO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Cam— OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I ant 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 j
L.-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 best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance 'th all Pertinent provision of tl-�e
L� Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l
PLUMBER-GASFITTER NAME 4tv9/2_4'a) ,__ ► 10 LICENSE#2,6q/ SIG
MP E MGF ElJP5—JGF❑ LPGI ❑ CORPORATION❑li PARTNERSHIP❑# LLC
COMPANY NAME cC �) r., -e2 41(.vkA,h��Jl _ ADDRESS 78 /Nods—r2 t 5—
CITY t� Q ��
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FAX CELL '7S '89W. a EMAIL o [Un„�
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