HomeMy WebLinkAboutBLDG-19-005866 '" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
- „ CITY �'� IL ,
'_'-- ' yil r vtiC n,J . j MA DATE 4ti I I 1 PERMIT# /LLi2/ -,-i J � �^
JOBSITE ADDRESS 5 5 14 6 hi.L f'ay S i• OWNER'S NAME . _
G OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
PRINT . •
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[ PLANS SUBMITTED: YES❑ NO Esi
APPUANCES'i FLOORS ! BSM { 1 2 ( 3 1 4 ( 5 6 7 1 8 1 s 110 j 11 12 1 13 1 14
BOILER
BOOSTER • i
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER i 6 �`
DRYER 'r
FIREPLACE ar_-
FRYOLATOR 1r i
FURNACE f-r ITT C, . ii, J
GENERATOR i
GRILLE a _. ..
INFRARED HEATER v i
'1:r.* • •'Y COCKS _
MAKEUP AIR UNIT `..
OVEN • _
POOL HEATER •r
ROOM/SPACE HEATER € N
ROOF TOP UNIT
TEST 1
UNIT HEATER if
1 `�
UNVENTED ROOM HEATER •
!or
WATER HEATER 1- - -. d_ s
OTHER I
,...
INSURANCE COVERAGE
I have a ctarent jlability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES (INO 0
1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND El
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requfed by Chdpter 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
hereby ce , that all of the details and information I have eubmmed or entered regarding this application are We and accurate to the best of my knowledge
and that ell plumbing work and installations performed taxer the permit issued for this application will be In with all F'erint provision of the
Massachusetts Scats Plumbing Cade and Chapter 142 of the General Laws. `� `/�!) (�
PLUMBER-GASFfrrERNAME 'LICENSE# ;�c1 A SIG NATIJdE
' AP I Lr� 6,A,
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M F 0 JGF❑ LPGI❑ CORPORATION Iff • zfam PARTNERSHIP❑# I LLC❑# D
COMPANY NAME: i9 L/14 Ti2)ti4.`.. .../1,a-. ADDRESS ,30 '?,104 1-S s-. ',lC>6' _ 7
CITY y'fi r/1ti Cu 1 STATE Ism ZIP '6 ,2.Oa 5� ') - (,i i
FAX _----_--- CELL) IEMAIL cTGtV!/./l/t'> 574,3 irD C'�IIrS'!L;, C e"..,
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