HomeMy WebLinkAboutBLDG-20-005106 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
W` 4;6�-'6" CITY\trt rotil MA DATE 7 Li a26 cJL/6I PERMIT# �:�/✓ OO'?��674
JOBSITE ADDRESS 60 w;IO Av Sf Ca/ /Q R NAME lLAi"( CtI4c1 4 n
OWNER ADDRESS TEL-7 7 ti ?G5 YG/ FAX
•
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL, ]
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES g] NO❑
APPLIANCES 1 FLOORS-+ BSM 1 ? 3 4 5 6 7 8 9 10 'I'I 2 1 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE j
DIRECT VENT HEATER
DRYER j
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER _ I
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN I iI
POOL HEATER •
ROOM/SPACE HEATER '
ROOF TOP UNIT ,
TEST t s ilt'IE -
UNIT HEATER
Ut4VENTED ROOM HEATER • B L i L D j N > d _
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES.gj NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE EY CHECKING THE APPROPRIATE BOX BELOW
O LIABILITY INSURANCE POLICY fc] 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 lication 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 co ance with Pertinentiirovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / "�f.
PLUMBER-GASFITTER NAME , ��/,3 J LICENSE#f 6�QI SIGNATURE
MP MGF❑ JP 01 JGF❑ LPG' ❑ CORPORATION❑# PARTNiRSHIft# LLC❑#I
COMPANY NAME -J• ( ,Lt4 S' jILA ADDRESS(:) (1 NIL/Lv / co
CITY lii/kt.c.j4 STATE fl'' ZIP 093 60 TEL 60 7 '1
FAX CELLO/7 ,°'( :r)-KY0 EMAIL �.1�'][,• 1 I i�.l� 7. a�'!�c.��.�,
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