HomeMy WebLinkAboutBLDG-23-9567 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS "I t U►�z�� R.o�n�r OWNER'S NAME_imV F trb at\l-s
GOWNER ADDRESS Same TEL&i7• -071 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:Fa, RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO gi
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/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
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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 al NO ❑
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 signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER El 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 ..a.fiance with all Pe�1[�enI 'si the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \
PLUMBER-GASFITTER NAME b�'v 4-1:) F3i/04611'�. LICENSE# l-. c1 SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPGI ( CORPORATION M#Coal I t?`1SPARTNERSHIP❑# LLC❑#
COMPANY NAME =/ 3 i EiRK) PIP,OPA-N6 ADDRESS PC 1?�O)S I),0 7
CITY SO2T1-A 0f k)iJ1S STATEM/\ ZIP C' Z!c't"C) TEL 50 .7470 A'775
FAX 5C)&3 7100 I e 3 3 CELL 50ii3 .A 3 7' d 4`t _ EMAIL C t;cr A..'ij_, t�'z I i��i'Zt it�/1 e