HomeMy WebLinkAboutBLDP&G-24-583 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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ADDRESS NAME—RG �/ a �/
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INSURANCE COVERAGE
b I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1---.17r0 J
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I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i' OTHER TYPE INDEMNITY BOND Li
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 signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ^I AGENT
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 best of my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the 'Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME; �� rQd LICENSE# ��� ¢SIGNATUR•C//
MP-t MGF JP al JGF LPGI CORPORATION erErfifcp PARTNERSHIP_1# 1 LLC;=,If# -
COMPANY NAME://I/7 a/i//s �cf/J/C 7 ADDRESS /( ///? T/ '_-- ------ ---- —`..-C
CITY �{/. Q.°i9lO4✓+r4 - . ....... . STATE i 1 ZIP I-Oa?LS73ITEL 724- -‘'G7a ' 1
FAX CELL: EMAIL�¢lp/(psdoiGtS��IIIIGt��Q —._ .__._
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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aZ,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Y Gi I"/��t�J f�i MA .DATE 6—2.7'-aq PERMIT# &pp 91/ s 3
JOBSITE ADDRESS I % I L cr'/ '���vy e ✓ k c I OWNER'S NAME k 1 - C /
p .OWNER ADDRESS I I TELL IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMEA T:1301--r PLANSNorm SUBMITTED: YES 0 NOD
FIXTURES I FLOOR- 1 2 10
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CROSS CONNECTION DEVICE
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DEDICATED SPECRL WASTE SYSTEM
DEDICATED GASIOfL/SANO SYSTEM 1111111.11111.
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DEDICATED GREASE SYSTEM
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SERVICE/MOP SINK ' MIN IIINS M. MIN.JIM �R miW 1111111.'1
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• INSURANCE COVERAGE: •
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES g-NO D.
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY^HECKi•IG THE AFPROPRL'TE BOX BELOW
LAE,'LITY INSURANCE POLICY Q" OTHER TYPE OF INDEMNITY❑ BOND❑
OWNER'S INSURANCE WANER:I am aware that the licensee;foes 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
I hereby certify that all of the detak 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 with a8 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME, 41,r/44/5'''/f-i't..4/$' - LICENSE#IM'[d'C`j SIGNA
MP[ JP❑ CORPORATION PARTNERSHIP❑#1 I LLC❑# J
COMPANY NAME VJ11b1 n75 1-/-i iv ...L1 c ADDRESS //l'll.>t it'
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