HomeMy WebLinkAboutBLDG-18-005223 _ `_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-, 'r� s CITY c30:-. /..ki-i b�\\ MP� DATE ,3/2-2-1 l PERMIT* Mf7"/$4d9�e12�
JOESITE ADDRESS .7 ()lima( 51- OWNERS NAME_&tD� I Secky\
GGWNER.ADDRESS 7 Q1Lve( --1--- TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ,
PrdINIT
CLEARLY NEW RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-I FLOORS—h BEM 1 2 3 4 5 6 7 8 9 10 'VI 12 13 14
BOILER —_
BOOSTER
CONVERSION BURNER
COOK STOVE )
DIRECT VENT HEATER
DRYER '
I
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR. I
__.
GRILLE __- -
R
GILE INFRARED HEATER �^' .._ . I
LABORATORY COCKS t
MAKEUP AIR UNIT 2 2 2� 1
OVEN _ �tOR i
POOL HEATER ttff.._...„._-6-11';GI:-
�,^F�j
ROOM I SPACE HEATER IROOF TOP UNIT
TEST --
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER
OTHER I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES X NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY N 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.
i
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT i
4- 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 complianc •th all inent provision of the
NIT!,
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE# SIGNATUP
MP ❑ MGF El JP X JGF❑ LPGI ❑ ) CORPORATION❑# /PARTNERSHIPP'❑#r LLC❑#!: 1
COMPANY NAME J1 �d�0-ey Plu a l b;n I ADDRESS 7 t� 4`t2- Ofiro t �d
CITY SVu N AtieteA)-1-AA. STATE in 4 ZIP O tt9 4 TEL So8-Z'ZJ` Z 7
FAX CELL C41'22)-5251 EMAIL Ji-avorvey 6 I C=4"..cc,'L. cm ni
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