HomeMy WebLinkAboutBLDG-20-000769 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
64,1" CITY Yi 'Ki,Gl Of. MA DATE U ' cr L -` / PERMIT# `*.e&-ao o7,
JOBSITE ADDRESS OWNERS NAME R-ft
OWNER ADDRESS La C• Z c2 ICJ i i TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:Jg7 RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS-4 BEM 1 ? 3 4 5 6 7 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE _
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT iR € c E I V - ❑
OVEN
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST _.. ---
UNIT HEATER v _ — ---r
INVENTED ROOM HEATER 0 �I
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of 1 GL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE 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.
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 nd accurate to the b t of my knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in pit c 'th all Pertine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE# -,� 9' SIGNATURE
MP❑ MGF❑ JP HAKE/
❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME P 7 PlhC ADDRESS 5 T 441 C1A-S-
CITY -Dv -- STATE let ZIP 023 C TELS .'3i73 g/
FAX CELL EMAIL PZ.-C � r-c eci C r/
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