HomeMy WebLinkAboutBLDG-18-007037 E
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1:�;6L..� CIT`( �-��Gv MA DATE PERMIT#/m417-/ff G0 M,j/
cl-
41
JOBSITEADDRESS 7 /'t &'O c; y 5' OWNER'S NAME ��1" 1�i~ 3G GWNERADDRESS f42 W4A''tid- 6:;?_ RI~ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
PRINT
CLEARLY NEW:❑ RENOVATION: j?' REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES T FLOORS--r
BSM
1 7 3 4 5 6 7 8 9 10 VI 12 '13 I 14 I
BOILER r i
BOOSTER
CONVERSION BURNER
COOK STOVE i
DIRECT VENT HEATER —j
DRYER
i
FIREPLACE
• FRYOLATOR
FURNACE _
GENERATOR.
GRILLE —
INFRARED HEATER
a
LABORATORY COCKS •
MAKEUP AIR UNIT • '
OVEN L__I
POOL HEATER •
ROOM I SPACE HEATER ; �/ `� _
ROOF TOP UNIT 3Y
TEST - . ......... __ �'_
UNIT HEATER __
INVENTED 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 C
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 13' -' 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
',1-. 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
L0 Massachusetts State Plumbing Code and Chapter(� 142 of the General Laws. . ��
PLUMBER-GASFITTER NAME J t�i g.ib-,-�JC Y"` LICENSE SIGNATURE
13�� r;
MP ❑ MGF❑ P JGF❑ LP GI ❑ CORPORATION[(3/6 LI PARTNERSHIP❑# / LLC❑# /
COMPANY NAME Pl(Jmb7,Nr `�iVC-, S 53 ( LG%�t-b a-' ` (J'C A'CC 6- t?
AMC � � ADURES., .7
CITY 9)y/Yl(fU01 STATE Ala ZIP 6p360 TEL 77 V 773 'L/5O
FAX CELLO '6 755-I EMAIL'peO01u�e(vmk:•, jNC._ e Vc-G;ZC,4/. A-
. / 6 47
I
I
I
1
G]
C
4
1 w
I
1
1
1
1
1
1
a., O 0
4
O g3 0 .
1 1 co
I.' I o
a G
1 4
2
1 ; .. cri-_ a
, 1 1Lii
1I a C4 c
Eli
1 co
E.
I-- L_
o
/ 1
1c
, r;.,, ,.
i t i
/ F 4
1
c