HomeMy WebLinkAboutBLDG-17-006413 MASSACHUSETTS UNIFORM APPLICATION FOR A P RMET TO PERFORM GAS FITTING WORK
`tom,e :74
e; !nI S �q b--- --17-CO tI/.% k ,s, CITY 6 MA DATE PERMIT
JOBSITE ADDRESS r- �t� 0 IVNER'S NAME
GOWNER ADDRESS (A - �/+G'yr l 4 6 v 7 1 TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL L
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES E NO❑
APPLIANCES 4 FLOORS—# BS1u1 1 2 3 4 5 6 7 8 9 10 'I'I 12 '13 I 14
BOILER
BOOSTER -
CONVERSION BURNER i
,
COOK STOVE
I IIIDIRECT VENT HEATER I j
DRYER '
�Ii
FIREPLACE MINI
FRYDLATOR FURNACEGENERATOR IIIIIIMEg
I J
GRILLE
' INFRARED HEATER ■ ■ ____I
LABORATORY COCKS
MAKEUP AIR UNIT
POOL HEATER
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST ...._ p • ____••_ _ ___
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
0;'HER
L C—L i... /1-/e..Y ei ' t UT. / 6 r.
_ 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of WOOL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY FGffSIQGTHE.APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
11
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 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat o 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 rtinent provision of the
Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
4 /3,---r PLUMBER-GASFITTER NAME LICENSE#/ 'IGNATU ,
MP MGF UP GF LPGI CORPORATION / PARTNERSHIP 0# LLC D#1
COMPANY NAME I064t
7C ! q- ADDRESS � tr IAM /
,)j
CITY / f\ ,kO
v 7 t,) STATE z/ —+' 1 ZIP 0 2_6 7 TEL 46 6 -1 'I 3
FAX CELL EMAIL
I
I ,
G2
ii
4
0
I h"
I C.
at
G'1
I
I 4
1 ;-,,,,
I
i
i
I
I
I
I
I
i ❑
z
in
I w LO
1 cr.?
I GO
cu
O
1 at rz4
GnI ram
I .. W >.
I
c
wco _
us '
O °"
a., H
cs
.71
Q.
CO
Lii
u_
I
I Q .
1
1 C)
I -4
w1
1