HomeMy WebLinkAboutBLDG-24-171 MASSAC USETTS UNIFORM APPLICATION FOR A PE IT TO PERFORM GAS FITTING WORK
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� CITY /. O MA DATE / , PERMIT# BL G 21- /7/
(� JOBSITE ADDRESS 2M ('r/5/�/f/ A4/.yr OWNERS NAME �' c
<P OWNER ADDRESS / //// k'//7 TEL ' — ?7 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0
PLANS SUBMITTED:YES NO 0
APPLIANCES-1 FLOORS-. EiSM 1 2 3 4 5 G
B 12 13 1"
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT I-IEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM!SPACE HEATER1111 ROOF TOP UNIT =NT
TEST
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES OA NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g 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 General Laws,arid that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER❑ 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 best of my knowledge
"> and that all plumbing work and installations performed under the permit issued for this ap lication will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP❑ MGF❑ JP fisL4._JGF LLPN=I
" � RPORATION❑# PARTNERSHIP❑# LLC❑#COMPANY NAME ‘14\(�c) ADDRESSS7 F/-c)
CITY I GI 1y S STATE 1\44 ZIP
TEL
FAX CELL EMAIL
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