HomeMy WebLinkAboutBLDG-18-000665 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
y, CITY VA-AMO J 1 4 MA DATE 07 /6 ( / i 7 PERMIT# /Y-�CCPu S�
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JOBSITE ADDRESS 2-1( jti f t *-i./2. LA/ OWNERS NAME LAeLzI el /4- C.,4
OWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[13/.
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: T PLANS SUBMITTED: YES ❑ NO 2
APPLIANCES.I FLOORS-4 BEM 1 2 3 4 5 6 7 8 9 10 'I'I 2 1� 13 11
BOILER
BOOSTER ._,
CONVERSION BURNER,
COOK STOVE t — I
DIRECT VENT HEATER
DRYER .
i
FIREPLACE
.
FRYOLATOR
FURNACE
GENERATOR
GRILLE —�
INFRARED HEATER
LABORATORY COCKS I
MAKEUP AIR UNIT
OVEN i
POOL HEATER
ROOM I SPACE HEATER I
ROOF TOP UNIT
TEST j
UNIT HEATER 7' I '4_ If
UNVENTED ROOM HEATER �- C
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or it substantial equivalent which meets the requirements of IVIGL.Ch.142 YES 1O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I. 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 Elli
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 best of my kno edge
and that all plumbing work and installations performed under the permit issued for this application will be in complia . ith all Pertinent provisio f
4 Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTERNAME ►V'& L;a SiLVA LICENSE# 139s~ S `N RE
MP ❑ MGF❑ JP Q/JGF❑ LPGI ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑#! I
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CCOMPANY (NAME �/L✓1� J �iklwvb i�1/�i 4 eJ�j I !ll� AADDRESS1�S �tj(1R.'SO LA
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CITY 141,4,lnrjS STATE/14A ZIP 026 a 4 TEL
FAX CELL-774/C! G -0[76 EMAIL VQb,LiI)MC34 FQJ U& k, IL, " Cp.)
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