HomeMy WebLinkAboutBLDG-20-003139 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
&" CITY LJJ C. A rt.nrNp VII-1 MA DATE j l lri �OM PERMIT# 3�37
JOBSITE ADDRESS cR C I R.GV OPIA N O/Cr 44 OWNERS NAMEStjY) —t". lG12�
OWNER.ADDRESS 34,1►►r)P TELVeJ-6o$"/J63."FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Of
PIUNT
CLEARLY NEW:2 RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS--' IBSM 1 2 3 1 5 6 7 8 9 10 '11 12 '13 1
BOILER
BOOSTER
- CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE 415 LoCj /Alsozr
FRYOLATOR
FURNACE
GENERATOR )4 ,
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN it
POOL HEATER •
ROOM;SPACE HEATER
ROOF TOP UNIT
V TEST E ti F P ,
UNIT HEATER i
UNVENTED ROOM HEATERDit
1
• WATER HEATER ` a
OTHER $ _
� is •�.: ,/(,� '� r i I I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of ItIGL.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 ❑
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
` Massachu tits General Laws,and that my signature on this permit application waives this requirement.
•
Lrrvn 7i CQJV1(' CHECK ONE ONLY: OWNER.14 AGENT ❑
SIGNATURE OF OWNER OR AGENT
\` C I her 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 complia e with all Pertinent.pr�uision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r(
/
PLUMBER-GASFITTER NAME LICENSE# /o44.4-. ) SIGNATURE
MP ❑ MGF® JP ❑ JGF LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME ADDRESS
CITY STATE ZIP TEL
FAX CELL EMAIL
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