HomeMy WebLinkAboutBLDG-20-002261 7d
` '.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
L J CITY il.1/44%Jw0cl1' h MA DATE /0/ z1 J i
PERMIT*&-Neb off!`lifoZZ�Of�
JOBSITE ADDRESS 11 LAV e...mi Ab OWNERS N.AMEbtM.U J hU
OWNER ADDRESS ill LA►CQv...dab TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
PRINT
CLEARLY NEW:[Y RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO[r
•
APPLIANCES FLOORS-* BEM 1 2 3 4 5 6 7 8 9 10 1'1 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE �— I
GENERATOR. _
GRILLE
INFRARED HEATER •
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM I SPACE HEATER i
ROOF TOP UNIT
TEST . . .._...._
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER I
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements at GRCEl EYF` •re l
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAC BY CHECKING THE APPROPRIATE BOX BE.0
•
•
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ *I)I) 2019
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage req i
` Massachusetts General Laws,and that my signature on this permit application waives this requirement. By: NT
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT J
• 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 P "the
t Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME `V i 461 Li s;L j,4 LICENSE#c3!3' —1 S `NAT ,
MP ❑ MGF❑ JP[✓r JGF❑ LPG' ❑ CORPORATION❑#i 4,
PARTNERSHIP❑# LLC❑
COMPANY{�IAME31t✓A 0" bi,AJG)//eA' ,i6 ADDRESS "SS
CITY 41/A ✓U f 5 STATE ,I- ZIP OC G°/ TEL
FAX CELL77c Q 3b 6l 7r EMAIL V'>! bso/P7 Q 4�064 i` • COM
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