HomeMy WebLinkAboutBLDG-17-001612 •r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`* CITY j a r Gvt- 4 MA DATE W.)- �//( PERMIT#/9/42b-17'W/6//2
JOBSITE ADDRESS 7 U W j Cr i-Pete)..-/'40tgieR'S NAME , 11//-9/c v(a
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Eji
PRINT
CLEARLY NEW:RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS-+ BSI1.)1 1 2 3 4 5 6 8 9 10 11 12 13 I 14
BOILER I _
BOOSTER _
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER _
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT '
\I OVEN
1 POOL HEATER T
ROOM/SPACE HEATER
ROOF TOP UNIT
VI TEST
UNIT HEATER
% UNVENTED ROOM HEATER 1
WATER HEATER _
OTHER
_ I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES In NO ❑
4 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY�J OTHER TYPE INDEMNITY ❑ BOND ❑ j
o d 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 tru- - . 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 co. • _ re with all Pertin t pr ision of the
Massachusetts State Plumbing Code d Chapter 142 of the General/ Laws.LO /� Gam/'�`�
PLUMBER-GASFITTER NAME a tr; d g vv� LICENSE#J33 O SIGNATURE
MP❑ MGF E JP JGF E LPGI ❑ CORPORATION El# PARTNERSHIP❑# LLC❑__ss#
COMPANY I\I ME v 4. '"l1 ADDRESS /a( ti IT v-e-0ti d6e- fed,
CITY 7`cr` (,i STAT ZIP U a- d 1— TEL 5-6g'. 9,.)--— G V/ "7
FAX CELL EMAIL /
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