HomeMy WebLinkAboutBLDG-18-002668 •- ,J.. MASSACHUSETTS UNIFORM APPLICATION FOR A. PERMIT TO PERFORM GAS FITTING WORK
i ce` mt,) ri-
-fn r_,J ✓c #1 r 0 ( PERMIT *Pb -/t 00' 665
•:• z_ 6" CITY ��cZ! E1 �j (�4A DATE
JOBSITE ADDRESS ?a'( C ` .4 S,al- OWNERS I M'E`Ug (9/Y
GOWNER.ADDRESS -J qr P TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL DUCATION,AL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW: gNOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 5 9 10 11 12 13 14
BOILER
BOOSTER ______i
CONVERSION BURNER _ •
COOK STOVE
DIRECT VENT HEATER I
DRYER '
i
FIREPLACE I
FRYOLATOR I
FURNACE J ' 1
GENERATOR. I
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT .c0,5(tor ______,!
OVEN
POOL HEATER 1
ROOM/SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MU.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE ECKING 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 Elli
J 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 m knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P ent pr on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.Lo
PLUMBER-GGASFITTER NAME LICENSE# j S�-�-a SIGNATURE
MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑#i:
COMPANY NAME l.g t7 C.c-/ J:/// &ADDRESS ce2<=t- tf2A l )
CITY g $ c, STATE /�c�( ZIP �T `7 TELr ?/
FAX �/ o��/'� ��
� EMAIL
I
I
I
co
w
0
Z
I bw
1 U
w
1 rr,
I
I 4
I
1
1
I
1
I
1
I
1 . 0LI
r.
1 O Z
14
O
LW
1
cu
I .. Cr-) CO I;
-C ILI - >-
..
I Q u4
ra.
ro .1
04
04 I—
Mti
[—! O_
a.
< 69.
CO Ill
I— LL
I
1 EfJ
Ie" kj.. .
i LA
I Z
i�
1 w
I � li A
N
c.