HomeMy WebLinkAboutBLDG-25-110 :1-4-N..... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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N CITY i MA DATE PERMIT#QLpG- ZC--//d
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JOBSITE ADDRESS n 9 '--_JJC5 T ye„co10�-tL OA OWNERS NAME kelly Mar.'-•
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OWNER ADDRESS r r i
TEL tiro 1 `t e6 56 f(o FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL EI----
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: a PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 71- FLOORS-+ BSM 1 2 3 1 5 6 7 8 9 10 'VI 12 13 1!
BOILER
BOOSTER 1 —j
CONVERSION BURNER
COOK STOVE
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DIRECT VENT HEATER
DRYER `-- I�
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FIREPLACE
FRYCiLATOR _
FURNACE
GENERATOR.
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GRILLE
INFRARED HEATER I
LABORATORY COCKS
MAKEUP AIR UNIT . .. __I
OVEN -- 1
vPOOL HEATER
ROOM!SPACE HEATER '
ROOF TOP UNIT
_. TEST
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UNIT HEATER P 1
' UNVENTED ROOM HEATER --
WATER HEATER
OTHER
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INSURANCE COVERAGE
-v I have a current liability insurance policy or its substantial equivalent which meets the requirements of IUIGL.Ch.142 YES Er140 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
lik LIABILITY INSURANCE POLICY s-- OTHER TYPE INDEMNITY ❑ BOND ❑
Q• OWE ' INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
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ph c 9 usett• General , rid that my signature on this permit application waives this requirement.
CHECK► NE ONLY: OWNER [� AGENT [—j'
SIC I , UR.E OF OWNER OR,AGENT
"i-• I hereby certify that al of the details and information I have submitted or entered regarding this application are true d 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 ompli ce with all Pertinent
`` Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
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PLUMBER-GASFITTER NAME elv.5 'Vol�*t„ LICENSE# 3?Ck l SIGNATURE
MP 0 MGF❑ JP R'JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Petit- ?k., i,D 1tee,p ,� ADDRESS 51 5c- �, � S'? fL _
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CITY gyahA it.
5 STATE n/Ck ZIP 0 40 ( TEL 9)t! 836 Cni
FAX CELL 2 7 Y 6.?6, 6 A.( EMAIL
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