HomeMy WebLinkAboutBLDG-25-23 #24 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY // fir) . MA i di F #[SLDG 2-j L3
� / DATE � 0 �S PERMIT,� j''lees
JOBSITE ADDRESS � '� `''A�' OWNERS NAME �i"`
OWNER.ADDRESS 2/ 17444
TEL ? 1.4 24... FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BEM 2 3 5 6 7
+ 9 10 'I�I 12 '13 14
BOILER _ _
BOOSTER j
CONVERSION BURNER '
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE - R E E D
! 4/
GENERATOR _
GRILLE I
INFRARED HEATED. IA(_ 08 ?025
LABORATORY COCKS
MAKEUP AIR UNIT t'
OVEN 1
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST . . ...
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 MGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE- GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY VA 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 j
` Massachusetts General Laws, hat my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATU OF OWNER OR AGENT
"�• I hereby certify that all of t 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 i ant provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.Cku
PLUMBER-GASFITTER NAME /YLa��s `� LC,,c LICENSE#�/ �� '�GNATURE
MP ig MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑tf PARTNERSHIP❑# LLC❑t
COMPANY NAME Y41 j;b c /.4� � 4, „ ADDRESS 00/ 754-«d R
CITY ip 54- yn-rer (vti i STATETE �OA- ZIP 62,�` TEL 7"� -•.a5 f /2/a
FAX CELL ‘6 S ( I - Y2- EMAIL r*t t5i M'� "G1- t,GG r Cowl
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