HomeMy WebLinkAboutBLDG-19-06712 N.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�'���.r CIT( �C(�/�JO�/�� ����� PERMIT,�
JOBSITE ADDRESS 3 L di. "6//4 OWNERS NAME AMA, 4'
OWNER ADDRESS TEL //FAY,
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 21
PRINT
CLEARLY
A RLY NEW:12f RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES•t NO❑
APPLIANCES • FLOORS—F 9SM 1 2 3 1 5 6 7 6 9 10 '1'1 12 •13 14 ?
BOILER ___I
BOOSTER I
CONVERSION BURNER '
COOK STOVE
DIRECT VENT HEATER -
DRYER
-
FIREPLACE
FRYOLATOR
FURNACE _
GENERATOR
GRILLE 1 1
INFRARED HEATER I
LABORATORY COCKS _ 1
MAKEUP AIR UNIT 2 b �11 I OVEN i
POOL HEATER • i
ROOM l SPACE HEATER I
ROOF TOP UNIT
TEST .. .. . .. C__ . - _.
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER
OTHER / .?/,errtt£ / I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Fj. NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [x OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S LNSLIRANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the i
Massa3rhussetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1
SIGNATURE OF OWNER OR AGENT
7:• 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 wit II Pertinent provision of the €
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME 661,77a/(i(J LICENSE ogfj1 • SIGNATURE
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MP MGF❑ JP ❑ JGF❑) F PGI ❑ CORPORATION❑ PARTNERSHIP❑0 LLC Z, �/
COMPANY NAME C✓'ex -YOotizi / I a& ADDRESSL P reezef e 64/6
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CITY : Q -6 b 9/G1 `�y� o 47 ' 1
STATE✓_� ZIP � TEL l�l'/ /
FAX CELL EMAIL
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