HomeMy WebLinkAboutBLDG-19-001218 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"� r`,-6 CITY t�a lg.Mi,e/ 4 MA DATEcYr- 2 2- 7 PERMIT#1,4P6 / -(X.3(All
JOBSITE ADDRESS 77 f 4,,,,-/c /roof Wd OWNER'S NAME IV. /.�/eP& 'A.
GOWNER ADDRESS 5*"N TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL
PST ❑ DU�AIIOIJ.AL E RESIDENTIAL ---
PRINT
CLEARLY NEW:i- RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS-4 Bsm 1 2 3 1 5 6 7 8 9 10 111 12 '13 1!
BOILER _ ----I
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
- I
FIREPLACE
FRYOLATOR
FURNACE _
• GENERATOR. I
GRILLE '
INFRARED HEATER i
LABORATORY COCKS . . f c tj r -'
MAKEUP AIR UNIT
t_
OVEN 1 i
POOL HEATER
ROOM I SPACE HEATER i I
, _ROOF TOP UNIT ittF AY_ F:
TEST -
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER
OTHER
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.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
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
`1s-, 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 corn ce with all Pertin provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. G �' --- -
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PLUMBER-GASFITTER NAME LICENSE#2 rice, SIGNATURE
MP ❑ MGF❑ JP GF❑ LPG! ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑#
COMPANY NAME 1444 e'G.." J A--V L1- ADDRESS G- /&:et 1-s,...7e - _
CITY ��G./{-et.- STATE/ZIA.- ZIP a � Y TEL
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FAX CELL EMAIL
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