HomeMy WebLinkAboutBLDG-24-324 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"kc CITY ��:�(Y1 v }� MA DATE 5- 3 " 4 PERMIT# ilk_ DC, Z�� 314
,' JOBSITE ADDRESS 3(y c c.IN T 4, .S } OWNER'S NAME rl/9J) &4224611E R
GOWNER ADDRESS 3(i,> C CA)rig .�'1 TEL6D ,3(pd 6L) FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL ,
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: A PLANS SUBMITTED: YES NO IN,
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ><
BOOSTER
CONVERSION BURNER
COOK STOVE ,
DIRECT VENT HEATER
DRYER
FIREPLACE
~FRYOLATOR
FURNACE
GENERATOR —
GRILLE _ _
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER E D
ROOF TOP UNIT
TEST
UNIT HEATER MAY 2 3 2024
UNVENTED ROOM HEATER '�WATER HEATER > _
BUILIID�Nr���FPARTMENT
OTHER By _ ____
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES !, NO X
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 General Laws,and that my gnature on this permit application waives this requirement.11
_e, L._ G CHECK ONE ONLY: OWNER "x AGENT
' SIGNATURE 0 WN OR AGENT
I hereby certify that all of the detai s 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 pro ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1
PLUMBER-GASFITTERNAME-Morn/lb ,J H b L 5 LICENSE# J ;;1, , SI, TURE/
MP )4, MGF JP JGF LPG! CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME: r fl Qint�J ,J )-)L1/f1}5 ADDRESS / 1D) il'/1) ,6�
CITY il/V f cA) STATE ll/ 1 ZIP 1:),,'- J C�;' TEL «, � / 1- ��� 0IP�i
FAX CELL EMAIL 1�" h�✓1n1 '7_� Lei,7D .Gof2
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