HomeMy WebLinkAboutBLDG-18-005968 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�°� CITY ' /4410(A, 0 MA DATE ' -3 l PERMIT# a'17-415?c 8
JOBSITE ADDRESS' r~ tl-QA5 Cv OWNER'S NAME ( f tc
OWNER ADDRESS oW$tom TEL
FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL LI RESIDENTIAL
PRINT
CLEARLY NEW:m RENOVATION.K. REPLACEMENT:{ PLANS SUBMITTED: YES ^ NO
APPLIANCES Z FLOORS—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHERaIr.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES V'NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT F.
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc e t e st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance al ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME SQ - CCeL 11.Ake,t} LICENSE#;1le22 SIGNATURE
MP V MGF JP( JGF LPGI fl CORPORATION[►✓# 3$ PARTNERSHIP # LC 1#
COMPANY NAME: Se ea_ I�t ���T1 �a�n �nc1 `I t I, DDRESS(,3ek_ 6e FeAfAcitA nR.ct l tryi� 31,0
CITY MAR-St&K Mtl.LS STATE fl4 ZIP 02w4le TEL;Ste 42$._^ (DODO
FAX L9,13 tn.?,-701#ELL` EMAIL ekt. .....� �.4