HomeMy WebLinkAboutBLDG-20-002768 SN MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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� � CITY MA DATE PERMIT
JOBSITE ADDRESS ( $ccdop w` ' OWNERS NAME -SC-4-)‹c'd
GOWNER ADDRESS ,9--q 5Ca `(v qd ' TEL FAX
TYPE ORPNT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2----
CLEARLY NEW:[`j-----RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-+ Bsm 1 2 3 4 5 6 7 5 9 10 11 12 .13 14
BOILER /
BOOSTER
• CONVERSION BURNER
COOK STOVE _/..
DIRECTVENT HEATER
DRYER / F
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE I r
INFRARED HEATER —~
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN —_ —I
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST .
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER
OTHER " J tt5kri 1 a2--
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ®/ OTHER TYPE INDEMNITY ❑ BOND ❑ I
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OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
� IMassacl ussetts General Laws,and that my signature on this permit application waives this requirement.
. CHECK ONE ONLY: OWNER ❑ AGENT ❑
•`' SIGNATURE OF OWNER OR AGENT
"i- 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 .with all ertinent provision oiethe
Massachusetts State Plumbing Code and Chapter 142 of the General ws.
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PLUMBER-GASFITTER NAME .3 J Y/ t Ca-G 0 LICENSE# SIG ATURE
MP !�J�GF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION #i 3ib� ,�P�A.RTNE HIP/❑�, 41, D LLC❑#I RI
MEFi1/4,,lbr, ,., ADDRESS 53 -- 'lw`0^ "FUC-'2%C
COMPANY €lA yd5b .,c9e3-- � ,.
CITY Ply/Inc-LA-CASTATE ac (.b'
ZIP 2-36O TEL 7 ' 7 7 �✓ i
FAX > � CELL v 3-1/6 ' 3 71 EMAIL �'` ✓ i1/'-c ,-/D 1.fle- V6.4-t7
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