HomeMy WebLinkAboutBLDG-19-002589 �` MASSACHUSETTS UNIFORM APPLICATION FOR A PERIMtT TO PERFORM GAS FITTING WORK
r J„ , ,s CITYiit,S'M6 MA DATE i0 r241 Zak " PERMIT# /)-r0/1-1700`
JOBSITE ADDRESS 7S IVI 1 n - ek OWNERS NAME Pthe VZ=C-n0,6ic ,_
GOWNER ADDRESS TEL HAY Z SS/
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALK
praNT
CLEARLY NEWK RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ N0t'_cl
APPLIANCES 1 FLOORS-4 Elul 1 2 3 4 5 6 7 5 9 10 11 12 13 I 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE _
DIRECT VENT HEATER _
DRYER
FIREPLACE
FRYOLATOR
FURNACE _. _,,.��.-.�.—
GENERATOR �W
i
GRILLE
INFRARED HEATER �_ -AM
LABORATORY COCKS t fW
,►�, 2 - P
MAKEUP AIR UNIT I '►�//►'r OVENioE Trf.N -
POOL HEATER • cs =
ROOM!SPACE HEATER , , \
ROOF TOP UNIT
TEST __...
UNIT HEATER
INVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 4 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW •
•
LIABILITY INSURANCE POLICY < OTHER TYPE INDEMNITY ❑ BOND ❑
• 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
74•, 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
`k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
'41
PLUMBER-GASFITTER NAME Sea:..,, }-ka ant c..-ir+c-.r, LICENSE# Ictz Z SIGNATURE
MP MGF n JP❑ JGF❑ LPGI ❑ CORPORATION❑## PARTNERSHIP❑## LLC❑##
COMPANY NAME 1-40.n f r P A-- ADDRESS VO 43,OIC I9&
CITY e.-)f r-V, G2_ STATE l(h ZIP Gtt2,,c 2_ TEL 77f Z3e-GZe(d
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FAX CELL EMAIL .n r ?(K"+b: 7.V. -,4icatC r
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