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HomeMy WebLinkAboutBLDG-25-114 MASSA.CHUSETTS UNIF RM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lerai.L z•=JNl f /5606- 2t"— 11 ` ,1 ,y CITY CM Mr DATE PERMIT* �( JGBSITE ADDRESS GC OWNERS NAME ��u-�'117 a figc)c, GOWNER ADDRESS TEL FAX TYPE OROCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO APPLIANCES 1 FLOORS BEM 1 2 3 4 5 6 7 8 9 10 'I'I 12 13 14. BOILER _ ----1 BOOSTER CONVERSION BURNER _ COOK STOVE DIRECT VENT HEATER DRYER —�i i FIREPLACE , FRYOLATOR FURNACE GENERATOR. GRILLE . INFRARED HEATER I LABORATORY COCKS MAKEUP AIR UNIT I OVEN I POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST -. -- , UNIT HEATER UNVENTED ROOM HEATER WATER HEATER -r OTHER - I I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of WIGL.Ch.142 YES I NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ I • 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 "i-• I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate t e st of my knowledge `� and that all plumbing work and installations performed under the permit issued for this application will be in corn ' ce wi rtin t provision of the �• Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `Z PLUMBER-GASFITTER NAME LICENSE# 2/77 SIGNATURE MP ❑ MGF❑ JP.JGF LPG ❑ C R ' PAT ON❑# PARTNERSHIP❑# LLC❑# COMPANY NAME ) ADDRESS (0 fl ,�/ I " LEB2o2o2 , J CITY STATE ZIP el v'( �J � ?t ,,✓✓ FAX CELL` O6 ?�� "' �1j� EMAIL 0 F"^ I L) I r Cori 4 H UD G1 ram- F- Vj tU fa.( l-- O a _ . fan a o Cri — FitiC7 (A, CA3 tu rcril 5 > H L�q coo Ly MN co-1 S: r� V