HomeMy WebLinkAboutBLDG-20-000479 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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sw CITY }''"�Y yr ()a.;" i4 MA DATE '-'7 `c7.3 —i g PERMIT#r*P6 06149 yT F
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JOBSITE ADDRESS J o c.1 ( ir'e ar ci 5+; OWNERS NAME C72( /r i_ 1. i
OWNER ADDRESS r6 6.01 Q TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL al-----
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CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS— B81v1 1 2 3 1 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 HEATED. H -
LABORATORY COCKS .4KP ,
MAKEUP AIR UNIT
OVEN 4' ' i
POOL HEATER
ROOM I SPACE HEATER —T
ROOF TOP UNIT
TEST -..
UNIT HEATER
UNVENTED ROOM HEATER 1 I
WATER HEATER 1
OTHER 1
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L� OTHER TYPE INDEMNITY ❑ BONE) ❑
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.
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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 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 compliant wi all Perti e�rovis�he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1
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PLUMBER-GASFITTER NAME LI ENSE# SIGNATURE
MP I MGF❑ JP ❑ JGF❑ LPG' ❑ CORPORATION #F PARTNERSHIP❑/ LLC❑# 1
COMPANY NAME as ecif _f U IM CAI 4! ADDRESS / 71 iio 1 N .to Li) el- f6I i
CITY S. 141r isvto 014 STATE rAcr , ZIP a 24 t —0 g-23 73L-
y TEL � y
FAX CELL S 3f 23 73� �� EMAIL f'W" - --) (�--3 � l� G o 1!i(
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