HomeMy WebLinkAboutBLDG-19-004169 ,..- r!"
�-' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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e,,`t.6N CITY YPlfina MA DATE i' 04-4 al
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~r s JGBSITE ADDRESS
a $ O A-K 6-I tank,.As,"i- . OWNER'S NAME AI�G�A C-k w✓
GOWNER ADDRESS a 5 O fo-ic GL ei►n TEL *) VOL' ‘'76) FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL V
PRINT
CLEARLY NE'JJ:E RENOVATION: VI REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
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APPLIANCES TI FLOORS-� 6�•IJ� 1 3 1 5 6 9 10 11 1� 13
BOILER --I
BOOSTER --j
CONVERSION BURNER
COOK STOVE I _
DIRECT VENT HEATER
DRYER
FIREPLACE i
FRYDLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS I
MAKEUP AIR UNIT _
OVEN -
POOL HEATER I
ROOM!SPACE HEATER ?n
ROOF TOP UNIT
TEST .. ... . .. u
UNIT HEATER _.
UNVENTED ROOM HEATER I
WATER HEATER
OTHER _ I
. _
j INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of 111GL.Ch.142 YES g NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Clit OTHER TYPE INDEMNITY ❑ BOND ❑
I
• 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.
'r CHECK ONE ONLY: OWNER ❑ AGENT El
•-, SIGNATURE OF OWNER OR AGENT
s"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-GASFIT•fER NAME 4 k Ego K•y Ctt Fc LICENSE# 1(-7 4SIGNATURE
MP ❑ MGF❑ JP® JGF❑ LPG! ❑ CORPORATION❑#F PARTNERSHIP❑# LLC❑#
COMPANY NAME G iket4 AI COk P( 4•1.Satvcc,c ADDRESS 4i SCc(A8 e... ..Nit
CITY Li. rh�u�fl.A
Y STATE tYlif ZIP C)"." TELL°8) 8•rY)y
FAX CEL45o& 712 -01/y S-tiCe:
EMAIL ext•t yA- v.ca"'.
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