HomeMy WebLinkAboutBLDG-19-004159 '� killASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
6F CITY O?Si- dr-nnaafi) MA DATE PERMIT#ir-1,6-`9-GG W
JOBSITE ADDRESS ✓ V ,Y 4- S T OWNERS NAME AW746/17e:7 1-‘9 00(/
GOWNER ADDRESS a UI15'ink*y / TEL Pnc- /6 A
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL.®
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: le PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BEN 1 2 3 4 5 6 7 9 10 11 2 1� 13 14
BOILER __—I
BOOSTER _ _____i
CONVERSION BURNER,
COOK STOVE /
DIRECT VENT HEATER
DRYER '
, i
FIREPLACE
FRYOLATOR I I
FURNACE /
GENERATOR
L
GRILLE
INFRARED HEATER
i
LABORATORY COCKS r
MAKEUP AIR UNIT I
OVEN i
POOL HEATER • j
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
_
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES [�NO ❑
I IF YOU CHECKED YES,PLEASE.INDICATE THE TYPE OF COVE GE.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
iMassachusetts General Laws,and that my signature on this permit application waives this requirement.
- CHECK ONE ONLY: OWNER ❑ AGENT ❑ I I
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are truee�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 compliance I Pertinent prow 'on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE#096, SIGNAT .E
MP 21 MGF El JP❑ JGF❑ LPGI ❑ CORPORATION❑4PARTNERSHIP❑# LLC❑#
COMPANY NAME '74 04-4 FrA71J / ADDRESS Pr, -13 Ux 77 S
CITY 75(1(fri5 71-CP fi,4 STATE/' ZIP 0 Z' .6 7/ TEL /S/Y '/ Z/
FAX CELLc 10 ,/9 7 EMAIL -