HomeMy WebLinkAboutBLDG-20-001661 _ 'ti
' ' lifiASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS lb Ma-'h-t O V e. OWNERS NAME Ac+}- Crr'tav+-k
OWNER ADDRESS TEL50fr— 76?-03Cc/ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ET
PRINT
CLEARLY NEW:ir RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOEf
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APPLIANCES FLOORS—I BSM 1 2 3 1 5 6 7 8 9 10 11 12 '13 I 14
BOILER
BOOSTER _
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE • S ��019
FRYOLATOR
FURNACE
GENERATOR _
GRILLE f 1
INFRARED HEATER _
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN II
POOL HEATER 1
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current'liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES pf NO [J
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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LIABILITY INSURANCE POLICY OTHER TYPE INLIENINITI' ❑ 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 irgiabliali ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE#,37r/? SIGNATURE
MP ❑ MGF❑ JP X JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME 86✓14 St p1."w 3 AGtCI ^ f ADDRESS a /44oi1
CITY W or•Ce r STATE ZIP ON. 0 3 /� TEL
FAX CELL??y— ssa 3— (0 y�a EMAIL �i l Jr'C VI I s i f lu M b l h s - c d IA/
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