HomeMy WebLinkAboutBLDG-18-004931 �',' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
4 . CITY /L.,..� L. r(, MA DATE 3A . /r PERMIT# ,O6--it-ODY9'3(
JOBSITE ADDRESS f 6 / 1JP,#'y A Gv-c OWNERS NAME fl41 / 4/'/C✓.,
OWNER ADDRESS / TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IK?'/-
PRINT
CLEARLY NEW:[( RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BSM 1 2 3 1 5 6 7 ° 9 10 '1'1 12 •13 14
BOILER
BOOSTER —___I
CONVERSION BURNED,
COOK STOVE
DIRECT VENT HEATER I.
DRYER
FIREPLACE
FRYOLATOR _ 1
FURNACE
GENERATOR
GRILLE I I
INFRARED HEATER. 1
LABORATORY COCKS I
MAKEUP AIR UNIT
OVEN
i
' .;`
POOL HEATER . E_D
ROOM I SPACE HEATER r 0 tjo g) 1 I
ROOF TOP UNIT : Li 131
n
1 1, st* 0' 1n .. \
TEST _.. ... . .. I.
UNIT HEATER 1., e- '. e17
,,
UNVENTED ROOM HEATER 6L, _DI_ P q — I
WATER HEATER I Vr _
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES elt ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 2---- 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. I
-, CHECK ONE ONLY: OWNER ❑ AGENT ❑
•`' SIGNATURE OF OWNER OR AGENT
:I-, 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 all Pertinent provision�of the"
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME 5-aok 7-64,.,zj$e / - LICENSE# 306 y r SIGNATURE
MP ❑ MGF❑ JP [� JGF❑ LPGI ❑ CORPORATION❑4 PARTNERSHIP❑# LLC❑# I
COMPANY NAME J e-in r.3e F`, - je°/u-r..��y-; ADDRESS I er5 v _, 51 I
S CITY --eL., Y < f f STATE f^u ZIP Dy-&-75- TEL C08'yzz`1j 00j
FAX CELL EMAIL 1/i.
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