HomeMy WebLinkAboutBLDG-24-620 t\i
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
k _N CITY MA DATE i d tO L PERMIT tt.. QL ig""2-`` - at)
JOBSITE ADDRESS OWNER'S NAME NA-NAmtt4--.
GOWNER.ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL _EDUCATIONAL ❑ RESIDENTIAL❑
PINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES NO❑
APPLIANCES 71. FLOORS—F 6SM 1 2 3 4 5 6 7 8 9 10 11 2 1� 13 1�
BOILER _
BOOSTER
CONVERSION BURNER,
COOK STOVE —_,
DIRECT VENT HEATER _
DRYER
I
FIREPLACE 1
FRYOLATOR _______I
FURNACE 1
GENERATOR
GRILLE I
INFRARED HEATER — H
LABORATORY COCKS —~
MAKEUP AIR UNIT —1
OVEN i
POOL HEATER ,r, 7, x I
A
ROOM I SPACE HEATER 1
i 1
ROOF TOP UNIT
TEST ... . . ... . .. !CT..j �.-2(�2�F
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER
0Triivb tft e,Pun
V '---. j.---- _
II
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES ft10 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE. Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ BOND ❑
• OWNERS 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 D AGENT ❑
SIGNATURE OF OWNER OR AGENT
71-• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac urate 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
PLUMBER-GASFITTER NAME tie N 77,4 Mr®gr' >A°>` #/ SIGNATURE
MP I �1GF JP JGI- GI ❑ CORPORATION❑# PARTNERSHIP� r❑# LLC❑##
COMPANY NAME 6 /� --1-- /° i ADDRESS 2-55 �/V - O1 V /<�
CITY Y/' 1 RMOV ( STATE // T ZIP TE r U
FAX CELL EMAIL 44 n o 65
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