HomeMy WebLinkAboutBLDG-23-9322 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY \Ic,Y (Yl()11(�1-1[ MADATE �l laic) PERMIT# 13La_,-zs--__Z _
JOBSITE ADDRESS I Clp) L)L E- -- Sipe 4-- OWNER'S NAME St I1 i k„
OWNER ADDRESS Sc,,_f\-Q- TEL
TYPE OR FAy-�
PRINT OCCUPANCY_, TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL El./CLEARLY NEW:M RENOVATION:0 REPLACEMENT:❑
PLANS SUBMITTED: YES❑ NO EA.--
APPLIANCES Z FLOORS-{ FSSN 1 2 3 4 5 s
BOILER 9 10 11 12 13 1,,
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT FIEATER
DRYER -
FIREPLACE
FRYDLATOR - -
FURNACE ✓
GENERATOR
GRILLE -
INFRARED HEATER _ LH
LABORATORY CCOCKSMAKEUPKEUP AIR UNIT
OVEN -
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER r
UNVENTED ROOM HEATER
WATER HEATER L 1 g 2023 + 1
OTHER J
ti NT
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES�N0❑
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 ❑
• OWNERS 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.
3
CHECK ONE ONLY: OWNER❑ 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 PlumbingCode and Chapter 142 of the t P General Laws. I�
PLUMBER-GASFITTER NAME LICENSE#/D'66, 1 SIGNATURE
MP td-MGF❑ JJP�❑ JGF❑ LPGI❑ CORPORATION❑4 PARTNERSHIP( ' 0# LLC❑#
COMPANY NAME j IC-,. . ^ `AL-r��ji5.r,,'n��nppDRESS 7 c`Kt�rt- (47-�
CITY S,yi � i-c- STATE 11 ZIP G301.UCntn TEL L -�1(-'Iaf38
FAX CELL EMAIL 2,400\ R m Cu-/ ,.-2)() n,, J,
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