HomeMy WebLinkAboutBLDG-20-004232 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
=fit CITY :�'1 e A ��rc\C;v=Tv� i '� 1 e , C '� 0— 1
MA DATE I � � PERMIT �- G� y� a �
JOBSITE ADDRESS `JsC OWNERS NAMEVc.L\ cvs\e cv'
GOWNER ADDRESS 0.^c\Q R FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL RI
PRINT
CLEARLY
NEW:❑ RENOVATION:❑ REPLACEMENT:❑ L. . _ PLANSSU ITTED: YES❑ NO❑
BUILDING DEPART JT
APPLIANCES-1 FLOORS BSM 1 2 3 4 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 HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER red:� c- •�
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES SK1 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY VI.. 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 and accurate to the best of
my knowledge
and sac allttsSt plumbing work and installations performed of thethe permit issued for this application will be h q� po{► p' ``)nf the
Massachusetts State Plumbing Code and Chapter 142 of General Laws. ` �( CJc
PLUMBER-GASFITTER NAM J -,2 1�2i t< LICENSE# 10) SIGNATURE
MP❑ MGF❑ JP❑ JGF❑ LPGI[1] CORPORATION 0# PARTNERSHIP❑# LLC❑#
COMPANY NAME hv`ne t-:‘&a.% ADDRESS g,' ZyeAv\v‘m.3.41h0.44
CITY Kl ex. A A STATE M ZIP Q 0 TEL 5te•.71S 'Ot3(
FAX 5c6•"T'l qt-tto % CELL EMAIL .Uesa « IDIteviz,ziutk
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