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HomeMy WebLinkAboutBLDG-20-003829 '" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 9 =a=�- —�-, QMv Y ;f 6 CITY y ' MA DATE 1 9.. GL PERMIT# t3 �'-A© 0 JOBSITE ADDRESS It bur eT`I t N . OWNER'S NAME i)PL 4 C4-4C1S GOWNER ADDRESS TEL FAX_ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL['------' nuNT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 '11 12 '13 I 14 BOILER _= ■ BOOSTER CONVERSION BURNERI . — ■ COOK STOVE I DIRECT VENT HEATER j DRYER FIREPLACE FRYOLATOR FURNACE 1 • ° GENERATOR. _� � _____J GRILLE J ■ ■ ■ ■ ■ INFRARED HEATER ____, LABORATORY COCKS MAKEUP AIR UNIT III I , i� OVEN POOL HEATER ROOM/SPACE HEATER ■ ROOF TOP UNIT TEST _. j. . . .. . ......... __ . _._ UNIT HEATER UNVENTED ROOM HEATER 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 ❑'gO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY ECKIIIG 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 a d 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 compr ce I inent provision of the • Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `1 PLUMBER-GASFITTER NAME&-€ L c_ -'-c- LICENSE#1 Z.(007.2,_ SIGNATURE MP ❑ MGF❑ JP JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME )E e - CC PC-VMBTUC:. ADDRESS P.CO . Box /ZJ{e CITY .pt_ESTDACC STATE t A ZIP OM q4 TEL SZ)g Z9Z. 7L4g FAX CELL EMAIL 16C-CEC-CDEZEK-00t A-0Z--COP? /J4 I i�a I GQ �t r4 I 1 i I I I I i v- m I o c LrA 1 c 4 � F- j _ _ a " .L a- `� a .< o ao EL E a. C Ill LL W ILI .114Hr A. up IP tiw Cir1 C7 s Q ,1