HomeMy WebLinkAboutBLDG-17-003228 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ry CITY L,Ci. d�v^ 0\-0--✓ MA DATE 1 a l k$ 1 i 6 PERMIT# 1 17-0C1
JOBSITE ADDRESS 30 i2L on tt OWNER'S NAME P rci t R)
GOWNER ADDRESS S -ON TEL? ) j FAX —_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 12/
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:I}' PLANS SUBMITTED: YES❑ NO❑
APPLIANCES Z FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER ___
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
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 MGL.Ch.142 YES 0
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
I hereby certify that at of the details and information i have submitted or entered regarding this application are true accu to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFI I i tR NAME A/ Ices 730 LICENSE# SIGNATURE
MP[GF❑ JP❑ JGF❑ LPGI❑ CORPORATION 3 DI to PARTNERSHIP❑# LLC❑#
COMPANY NAME ad-Mgatt rz 2C4i ADDRESS S kc-e
CITY S_ wiLdset STATE_ Wcfxj ZIP D Co 6ct TEL
FAX Svb/_c({/ , j r0 CELL 7) G- ‘j j-36 EMAIL c9`�J �,/1 C�`J A2cr✓�iL, t Col.Cr�vl/J