HomeMy WebLinkAboutBLDG-20-005902 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
irl5' CITY (A)G ! I$I�M 0 ct/1�r MA DATE ' I „,1�PERMIT#/-)19':,2L0-do Th ,
JOBSITE ADDRESS I 37 k6- ./0,11,9 _, hi & OWN R'S NAME t
GOWNER ADDRESS 1 TEL 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL •• RESIDENTIAL
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CLEARLY NEW: RENOVATION: .., REPLACEMENT:' PLANS SUBMITTED: YES N0
APPLIANCES 1 FLOORS--{ BSM 1 2 3 4 I 5 6 I 7 8 9 10 I 11 12 13 `14
BOILER .-.-.
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BOOSTER t
CONVERSION BURNER
COOK STOVE / I
DIRECT VENT HEATER 1
DRYER
FIREPLACE
—
FRYOLATOR
FURNACE /
GENERATOR l i
GRILLE I ——
INFRARED HEATER
LABORATORY COCKS I
MAKEUP AIR UNIT , I
OVEN I
POOL HEATER , I J -
ROOM/SPACE HEATER —
I
ROOF TOP UNIT
—
TEST
UNIT HEATER I
UNVENTED ROOM HEATER
WATER HEATER __,_,_ a_ I
OTHER I j
Vy I —.
_ . . —
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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 BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY l 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 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 Pertinet prow io of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME /0/nA'S l.Oa616 4 A) -1 LICENSE#I gs?Q ,*7 SIGNATU E
MP j' MGF j JP JGF J LPGI _4 CORPORATION'' ## OS'j 1 PARTNERSHIP Lilt 1 LLC LJ#';
COMPANY NAME:1 /?Y-(, L I d aJG--y-CUO G;ti•(i I ADDRESS# 3 U g)(32,t SSA- 1)4l UC( J
CITY if"--M O ----1 STATE GI. ZIP' D,?-6 7e�- TEL i 5«-"2 3? ADD I s.
FAX' �� CELL{ 3 � /�Y3' MAIL '- a / G }L13� C�L�2t�1I,F y v�(( ,,, I
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