HomeMy WebLinkAboutBLDG-20-004373 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS 106 -c*fti` OCA Or OWNERS NAME l4 mo` o n
GOWNER ADDRESS /O0G 5( d y TEL- FAX
TYPE
OCCUPANCY TYPE COMMERCIAL d EDUCATIONAL ❑ RESIDENTIAL Et
PRINT
CLE A_RLY NEW:❑ RENOVATION: ❑ REPLACEMENT: Z./------- PLANS SUBMITTED: YES❑ NO❑ i
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APPLIANCES-1 FLOORS—F Elul 1 2 3 4 5 6 7 8 9 10 11 12 '13 14 1
BOILER a, ,
BOOSTER I
CONVERSION BURNER I
COOK STOVE
DIRECT VENT HEATER
DRYER
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FIREPLACE '
FRYOLATOR I
FURNACE
GENERATOR I I
GRILLE I
INFRARED HEATER - I
LABORATORY COCKS I
MAKEUP AIR UNIT I
OVEN
POOL HEATER • I
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST • • _ - - --
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES �0 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er OTHER TYPE INDEMNITY ❑ BOND ❑ 1
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1
Massachusetts General Laws,and that my signature on this permit application waives this requirement. !
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT J
.-1, 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 compliance with al rtinent provision of the
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME k S P,f-a- --il-.S±— LICENSE# i3a3 SIGNATURE
MP 2 .MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION # 3$Dej PARTNERSHIP El# LLC❑#
COMPANY NAME ems-(G hJ/,S'F 0,1 - ----(1,—-C.— ADDRESS PO (36)( 0.3 '7.3
CITY eiy� STATE gGc ZIP OP'5(-4? a TEL ,' l'SCC 76(D
FAX ( CELL EMAIL J GGcr(�y 31 7 14-+ J,Co►^-`
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