HomeMy WebLinkAboutBLDG-18-002485 j
J :::'-:,= MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
i `tE0g CITY Yar/✓I D 17 MA DATE ?4—r 7 PERMIT# -4G"/S--1 g9g
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JOBSITE ADDRESS - criv.„ i:�-.` OWNER'S NAME /CAi../j F- n
GOWNER ADDRESS T3/ Cry-71 Ai Z., .1 TEL ?7q~ ?G3" 7 7 FAy
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�*"..-
PRINT
CLEARLY NEW:E RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES FLOORS--f BSIJM 1 2 3 1 5 6 7 5 9 10 11 12 '13 1f
BOILER
BOOSTER j
CONVERSION BURNER.
COOK STOVE
DIRECT VENT HEATER
DRYER ,
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
• INFRARED HEATER ❑
LABORATORY COCKS
—41
MAKEUP AIR UNIT !
OVEN
POOL HEATER
ROOM!SPACE HEATER II IIIIIV:llgt : :'. '
ROOF TOP UNIT
TEST F - ---
UNIT HEATER P' I !i9 _
LINVENTED ROOM HEATER _.`_L _.
WATER HEATER
OTHER " C-4-
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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 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE EY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ 1
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.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑ l
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 corn hence with allPertin nt rovision of the I
�� Massachusetts State Plumbing Code and Chapter'142 of the General Laws k, /
PLUMBER-GASFITTER NAME LICENSE#pt 336,c/ SI KTURE
MP ❑ MGF❑ JP R-JGF❑ LPGI j❑f CORPORATION❑# PARTNERSHIP❑# LLC ElCOMPANY NAME tilke-�rta�¢-t� R C�'r 1`0 ADDRESS la 1%-l.61-k v l_,,\
CITY \kfMrutfl/1 Par al STATE Iv)' ZIP 0 c' 1 5- TEL) f- ) I- q.Q
FAX CELL? /'t-c2 I SSG q EMAIL Cr—vaCmv„,...1 33 c4r, i/ Le . 141 /e'1
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