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HomeMy WebLinkAboutBLDG-19-002974 _ MASSACHUSET T S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 7.2 = CITY yom14 -©tlr > . MA DATE ii 8 (C3 PERMIT# 426-/P- a?7 JOBSITEADDRESSI1_tU1) � F-DOWNER'S NAME j_ LI, OWNER ADDRESS {(1E o A Wre TYPE OR OCCUPANCY TYPE COMMERCIAL!,.x EDUCATIONAL 1___J RESIDENTIAL iN W PRINT CLEARLY NEW: RENOVATION: , REPLACEMENT:1.::=. PLANS SUBMITTED: YES ' NO`,-,' APPLIANCES-1 FLOORS--, BSM 1 2 3 4 5 6 7 8 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 ` INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES /NO I,,, I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY t ' 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 acc e t e st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance al ' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r.<n- LICENSE# 1(g22 _ PLUMBER-GASFITTER NAME SlisCW 1,4 it4A1Q, \' `1 SIGNATURE MP:/ MGF El JP F. JGF LPGIF CORPORATION 6 $3 PARTNERSHIP # LLC 3#? COMPANY NAME .eoce, 1,1 aA,o 6WipfritoiDDRESS 3.8 6) AMog k4k CITY NIAR-StbNs MAUS STATE[tY14LL ZIP rail;t4 TEL 503 ` 2,6 Tit)ao �� u k