HomeMy WebLinkAboutBLDG-17-004961 MASSACHUSETTS UNIFORM APPLICATION FOR A ER fT TO PERFORM GAS FITTING WORK
- ` :tw CITY (A) -ii/h MA DATE 3 Z7 i PERMIT�'f1L*-/7-{vV??'/
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JOESITE ADDRESS /// irribir OWNERS NAME )l�'✓�efril�
OWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL EDUCATIONAL
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PRINTOMAIERCIA ❑ DU�ATICiId.4L ❑ RESIDENTIAL
CLEARLYNEW:❑ RENOVATION: 2 REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO(f
APPLIANCES 4 FLOORS-4 BSM 1 ? 3 ' 1 5 6 75 9 10 11 12 13 14 I
BOILER
BOOSTER j
CONVERSION BURNER
COOK STOVE /
DIRECT VENT HEATER
DRYER
FIREPLACE '
FRYC)LATOR
FURNACE
GENERATOR. I
GRILLE
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INFRARED HEATER i
LABORATORY COCKS
MAKEUP AIR UNIT !
OVEN 1
POOL HEATER 1
ROOM/SPACE HEATER I
ROOF TOP UNIT
TEST . . .
UNIT HEATER
INVENTED ROOM HEATER I
WATER HEATER
OTHER I
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1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meats the requirements of MGL.Ch.142 YES 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 ❑
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OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the ll
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER DR AGENT
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
`I:- and that all plumbing work and installations performed under the permit issued for this application will be in oomph .with 11 7, rtinent provision of the
, iMassachusetts State Plumbing Code and C apter•142 of the General Laws. /� .i
PLUMBER-GASFITTER NAME 1 � "l/A LICENSE#1/0/2 SIGNATURE
MP 2" IMF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERS IP❑# LLC ❑#
COMPANY NAME Ktti / l,�! k �'f/ r ADDRESS 37 ed 4uke-
TELCIT eider/ STATES ZIP D 3 �f�0 `J�� �i �
FAX CELL EMAIL MAR 9 7 201?
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