HomeMy WebLinkAboutBLDG-18-004812 �•��. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
a.SLI4.4k, : CITY L(f'f12d1(7V! MA DATE v; /�re PERMIT#; I G'��'o� ��
JOBSITE ADDRESS 3.S q(44 /' /K OWNER'S NAME Afen4)
GOWNER ADDRESS37 9 fe bI All / TEL0 7/e Jf7 FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:[ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO�I
APPLIANCES Ti FLOORS--4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE €
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR _
FURNACE
GENERATOR
11111
GRILLE ■ ■ i
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _OVEN
POOL HEATER —� 1
ROOM I SPACE HEATER
ROOF TOP UNIT , P-E,► _
TEST •
UNIT HEATER in ILDI At •.4...
, .� :
UNVENTED ROOM HEATER a �__By 1 I ■i 1
WATER HEATER MI I
OTHER 1 i
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.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 ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the I
Ma usetts Geri ' Laws,and that my signature on this permit application lication waives this requirement. I
CHECK ONE ONLY: OWNER Er AGENT ❑
;� SIGNAT RE HER OR AGENT i
'� I hereby certify that all o he 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � N^
PLUMBER-GASFITTER NAME LICENSE#S/,j 7a b SIGNATURE ��
MP ❑ MGF❑ JP II JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑#t LLC❑#I I
COMPANY NAME S ADDRESS i, 4 Q _
CITY /3 all- STATEJ 1 if ZIP e5 2 ce7,5 TEL .3—°2" 3-73 aa77
FAX CELL EMAIL
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