HomeMy WebLinkAboutBLDG-20-0032 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
L`== 1" CIT( y ter yY104"'fkl MA DATE ) 2 `&-- ,i q PERMIT# / t'c- -r„ ,!27O
JOBSITE ADDRESS if buy, 7` 1 GM OWNER'S NAME P.0 C ( -
GOWNER ADDRESS 5'a-tYI TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [] *---- PLANS SUBMITTED: YES❑ N0❑
APPLIANCES 1 FLOORS-4 BSM 1 9 3 4 5 6 7 s 9 10 11 12 13 14
BOILER --I
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER i
_
DRYER �� _I__ 1
FIREPLACE _ '
FRYOLATOR _I
FURNACE
GENERATOR
GRILLE I
INFRARED HEATER --1
LABORATORY COCKS I
MAKEUP AIR UNIT I
OVEN i
POOL HEATER
ROOM/SPACE HEATER I '
ROOF TOP UNIT
TEST 9``_ ,
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 • YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE'A GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1'; OTHER TYPE INDEMNITY ❑ BOND ElI
• 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 ❑ l
SIGNATURE OF OWNER OR AGENT 1
7.I.: 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 ith all Pert€nei}t mkt' iron of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ... /Peat
PLUMBER-GASFITTER NAME cJ ce.H?cf. 1.)-' 1 1 e-V- LICENSE# t7-5 2).7 • SIGNATURE
MP [Tr MGF❑ JP ❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP/ ❑�t/�,,, LLC❑#i I
COMPANY NAME J �Yla 1 AA4 O1 P el„.., ADDRESS 717 IX005101.0 ( Lie fl `
CITY 5, l txv-ys4 6 11—itel STATE MLi, ZIP 02L L� y TEL 56 37 3.S g tI
FAX CELL 5 Q6G7-Q- EMAIL 1 03ec 2y v.%-e. I2 3 @ levelA , I .6 46
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