HomeMy WebLinkAboutBLDG-23-9333 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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== MA DATE PERMIT# BtD67-Z 3- 7
G JOBSITE ADDRESS le f ix(e`1 L,t. OWNER'S NAME IZ i ch R r ei Levis
OWNER ADDRESS SICC a-t.30 TEL 3L4- l`143 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY 'NEW:[I RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO IE
APPLIANCES 1 FLOORS-. BSw1 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
GOOK STOVE
R
DIRECT VENT HEATER
DRYER `1
FIREPLACE JUh 9 Q N23
FRYOLATOR
FURNACE B UJll nirv� � SENT
GENERATOR
GRILLE
WFRARED HEATER -
LABORATORY.000KS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED 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®NO❑
11FYOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY® OTHER TYPE INDEMNITY❑ BOND❑
OWNER'S INSUIWICE WAIVER:I am aware tnat the licensee does not have the i 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 certfy that as of the details and information I have submitted or entered regarding this application are true and accurate to the best of knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance - all P t vi on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASH I Iti NAME 1...45+€4- Wu eft. LICENSE# SI RE
MP 0 MGF® JP❑ JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Cap e_Ld c4 Tencto.rPor 4,414 at.04._r' ADDRESS at, Ni(G k4+ c11Eu U rt i t I
CITY 'ACCSk -ee STATE I'M ZIP 03l04" TEL 50�'4-1 -1
FAX to1A CELL yes-aye- EMAIL :1t4(C cs:�P el-VC cc.1n