HomeMy WebLinkAboutBLDG-18-00488 #10 L_,'.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
W j- t I
`: :t. r Cf Ty /�M4 OlA-(1k-._ €0A. DATE 7 - 0-1 I-) PERMIT f / /2'/3-000 /
JOBSITE ADDRESS IC/a geot 0.-0.--e__ ptr`-'+� -<. `-WI ERS NAME ( t o 5_i�
� 1 rut llvirl� + a
OWI IER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Rr EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 4 FLOORS—+ BSM 1 2 3 4 5 6 7 5 9 10 '11 12 '13 I 14
BOILER
BOOSTER
CONVERSION BURNER ,
COOK STOVE —�
DIRECT VENT HEATER _ 1
DRYER '
i
FIREPLACE I
FRYOLATOR
FURNACE
GENERATOR. II
GRILLE
INFRARED HEATER --1
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER. I
ROOF TOP UNIT ,
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER `._
OTHER
I
I
INSURANCE COVERAGE �� '
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES L'J ISO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA E 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.
I
CHECK ONE ONLY: OWNER ❑ AGENT ❑
J SIGNATURE OF OWNER OR AGENT
't-, 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 compile e w' all Pe 'neat ovi ' of the
�' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME R (,•)W-A-L-e---- LICENSE# 3;45-73 SIGNATURE
MP ❑ MGF❑ JP []' JGF E LPGI ❑ CORPORATION❑# PARTNERSHIP El# LLC❑# I
COMPANY NAME ADDRESS .49 laA v SY-a.a.Je k
STATE Siff ZIP Oa 6� TEL SOB b O /9`
CITY S' X/..-4-4440f,(41\_ TEL 37
FAX CELL EMAIL
,
I
1
I
G1
cal
G
z
i 2'
I U
w
I
1 co
1
1
I
I
I
1
Z
I G 2 O
I l7,
vi
H 4
C) L
co') CO w
Q .. .. _
A [
A CO ,4
C) o
-14 Fw °-
CI-
4: .
GO Ili .
S WI
I-- IL
1
11
0
I0
I C)
1
Co
1
i
C)
I C)
j
0
I