HomeMy WebLinkAboutBLDG-20-004989 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
M AIL., ` CITY 1-).:it w' ti;i 1 MA DATE '3 ...I G — 2.C) PERMIT# /.�=Y"� 10150`f re
JOBSITE ADDRESS ) L K r 1 g1-e,vt r 4�i VI OWNER'S NAME V e 11 V -( C�+
GOWNER ADDRESS 5 &wt - TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL lie*-----
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 0�� PLANS SUBMITTED: YES❑ NO❑
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APPLIANCES 1 FLOORS-4 BSM 1 2 3 1 5 6 7 6 9 10 11 12 13 16
BOILER —❑
BOOSTER j
CONVERSION BURNER 1
COOK STI ;
DIRECT VENT HEATER I
DRYER
. i
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS 1
MAKEUP AIR UNIT
OVEN
' POOL HEATER H -
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST .•. -
UNIT HEATER _
UNVENTED ROOM HEATER
WATER HEATER
OTHER 1
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of IUIGL.Ch.142 YES krNYS 13
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ,ZO,
LIABILITY INSURANCE POLICY 1e OTHER TYPE INDEMNITY ❑ EiONP ❑
2020
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(OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required b Calt` t Ba�N4�div t1�e�RTrviENT I�
Massachusetts General Laws,and that my signature on this permit application waives this requirement. `-_'`__ — I
CHECK ONE ONLY: OWNER ❑ AGENT ❑
�` SIGNATURE OF OWNER OR AGENT 1
'4, 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
`t f and that all plumbing work and installations performed under the permit issued for this application will be in compliance •th I Pertinent prow ion of the
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (/ L 1
PLUMBER-GASFITTER NAME LICENSE# 16 q SIGNATURE
MP AGGF❑ JP❑ JGF❑ LPGI❑ CORPORATION 0.47 PARTNERSHIP❑# LLC❑# 1
COMPANY NAME .:7-4-(1,--a J--r P( j i I0)65/ ADDRESS i"(7 A/ Lti i n5/6i-d G rat,P1,
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CITY , t akity p,A th STATEU / (a. ZIP 6). t 6 `7 TEL 5Cl 2-3 7 3 h g y
FAX CELL 3/t 1M { EMAIL 141� FYI ' 7 3 4 cy#14 !i r G C GY)
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