HomeMy WebLinkAboutBLDG-18-005000 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
11 CITY FRMOUTH MA DATE March 12, 2018 PERMIT# BLDG-18-005000
JOBSITE ADDRESS 180 SOUTH ST OWNER'S NAME KAMBORIAN LISBETH N
G OWNER ADDRESS 151 MASSACHUSETTS AVE ARLINGTON MA 02474 TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL RESIDENTIAL El
PRINT
CLEARLY NEW ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
_FIXTURES FLOORS , 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 1 11
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN _
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ❑ NO❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER OF 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.
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 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.
PLUMBER-GASFITTER NAME Richard Olsen LICENSE# 2166 SIGNATURE
MP❑ MGFEI JP❑ JGF❑ LPGI❑ CORPORATION❑# 2166 PARTNERSHIP ❑# LLC❑#
COMPANY NAME: ADDRESS PO BOX 2026,
CITY Dennis STATE MA ZIP 02638 TEL
FAX CELL EMAIL
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