HomeMy WebLinkAboutBLDG-18-000540 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY SDer-7,A t 4?i/1�DU-711 MA DATE 7/1-7// 7 PERMIT# t,-/ 1
70
JOBSITE ADDRESS i I NA•t/71 Ca/ L.IA''L OWNER'S NAME ✓�4,V /'//.,/
G OWNER ADDRESS TEL FAX
TYPE
R OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:ETDU PLANS SUBMITTED:YES 0 NO y�
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 /• L 0,0 4
ROOF TOP UNIT L.
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 [v rlO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details end infomnaton I have submated or entered regarding this applicatIon are true and accurate to the beat of my knowledge
and that as plumbing work and irsfallatlons performed under the permit issued for this application will be in comp wRq,dII Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 73 r/Ai✓ y,',6 64,rd LICENSE#//J 77 SIGNATURE
MP Er MGF❑ JP 0 JGF❑ LPG!❑ CORPORATION H# PARTNERSHIP 0# LLC❑#
COMPANY NAME G4Ppt. Loc Y? i✓G, ADDRESS P D • .B2>< y25
CITY i• 17eth iS STATE/'119- ZIP D 7 2f TEL Sbd -3ScP-Z2- e
FAX CELL EMAIL
krw-