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HomeMy WebLinkAboutBLDG-20-003468 #A _ -... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ����Jh C Q .1:- s` CITY co5-r\/ to (t� MA DATE ' .. 10 . i? E �` PERMIT.� P/�6--go 0/i'7..y , JOBSITE ADDRESS ( © /1 t OWNERS NAME �Q R.5 G / f-��RrY �R-, �ti yA i2. bg 9 FAX ... - OWNER.ADDRESS +�Qi TEL # 6 TYPE OROCCUPANCY TYPE COMMERCIAL g EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO1 APPLIANCES FLOORS- , BEM 1 2 3 1 5 6 7 EI 9 10 11 12 13 1! BOILER --I BOOSTER CONVERSION BURNER --I COOK STOVE — _ I DIRECT VENT HEATER DRYER __, i FIREPLACE FRYOLATOR FURNACE GENERATOR. GRILLE i INFRARED HEATER —1 LABORATORY COCKS 1 MAKEUP AIR UNIT OVEN i POOL HEATER 1 ROOM 1 SPACE HEATER i ROOF TOP UNIT TEST . UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of UM..Ch.142 YESX NO ❑ I 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 i Massachusetts General Laws,and that my signature on this permit application waives this requirement. ., CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 'fit-. 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 corn liance with all Pertinent provision of the • `Jl Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Pp J L CI .A}:1.4 LICENSE .pD 5 SIGNATURE MP ❑ MOF❑ JP,K1 JGF❑ LPGI❑ CORPORATION❑0 PARTNERSHIP❑0 LLC❑## COMPANY NAME ADDRESS / ?o Jo N.PN- FIA n uJ-A 97 CITY 3 Ri, uu S-ri STATE 'r \A" ZIP 0 7-CO 8 / TEL‘O E. 9-0-18�� /U FAX CELL EMAIL Psi 1700 G0 N1\C-PLC N"E-7-' I G'i 0 U 0 I C.� I 1 or.t N 4 I i rzc I 1 i z Co • o 0 LU 0 Lai 1.. CO CO £ �. - .. . . .... I L CO 1 CD o Er,. < rW 2, R. 64 DOill I CO . CA 0 %4 1 C,.) 0 1 c.. (- _,. . 1 0 ____ I = Ns .A I