HomeMy WebLinkAboutBLDG-17-005637 Le-..,.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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� ki_ 6 CfTY l/f�2i�lrlGd %� MA DATE l'/ PERMIT n�`�-G'U5 ✓�7
JOBSITE ADDRESS,26 47 a4t9 '- ' , �. OWNERS NAME ,/2LC�
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[- "'
PRINT
CLEARLY NEW:ZI------RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NOS—
APPLIANCES 4 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —I
BOOSTER
CONVERSION BURNER,
COOK STOVE /
.
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR I I
GRILLE
INFRARED HEATER
LABORATORY COCKS SHY CM 2Q1I I
MAKEUP AIR UNIT I
OVEN - CV-t4-- k, �3 3 I
POOL HEATER 1
ROOM I SPACE HEATER I
ROOF TOP UNIT '
TEST . . -
UNIT HEATER
INVENTED ROOM HEATER 1
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 41.10 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ "..--- OTHER TYPE INDEMNITY ❑ BOND ❑
LOWNER'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 all of the details and information I have submitted or entered regarding this application are true and ccurate to the best of my knowledge
`— and that all plumbing work and installations performed under the permit issued for this application will be in compli . ith all P ire t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.Li 1
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PLUMBER-GASFITTER NAME/,'6-,4 /J �'j44 TX4:f LICENSE 4//IV— SIGNATURE
MP ❑ IMF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑ti PARTNERSHIP❑# LLC❑#
COMPANY NAME/rll AM.r 'Gf ADDRESS 7 / Z/01 JV' f , < C
CITY / G -I# STATES ZIP ag 0 TEL ,5 :.2+37.�5- `7
FAX CELL EMAIL a .�I A cc44 c -- ieT'
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