HomeMy WebLinkAboutBLDG-17-004064 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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=.w-; CITY J0 yobe..4m. MA DATE ol7/d //7 _ PERMIT# &-4tJ'17 D ge'6G �
JOBSITE ADDRESS 0019 /4'(GlifF-t`)i -6M cOWNERS NAME -/n^' r
OWNER ADDRESS .S1�-rA.� f TEL '-----_, FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:VENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES NO❑
APPLIANCES 1 FLOORS BSI 1 2 3 4 5 6 7 8 9 10 'li 12 13 14
BOILER --I
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER C!': g Ill
FIREPLACE I° `
FRYOLATOR _
FURNACE ■ F ►�
GENERATOR - 11
GRILLE �:� �I® � ��1�
INFRARED HEATER � —
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LABORATORY COCKS • I
MAKEUP AIR UNIT
OVEN
POOL HEATER {
ROOM I 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 'NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [t OTHER TYPE INDEMNITY ❑ BOND ❑ I
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the it
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
I
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT j
•i-,, 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
\k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with a
all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of he General Laws. �r�yrv7'17
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PLUMBER-GASFITTER NAME A i 1 lA)ap -S LICENSE 0/S7?7 SIGNATURE
MP I MGF❑ JP ❑ JGF❑ LPG' ❑ CORPORATION(f]-'#E/ PARTNERSHIP❑# LLC❑#
COMPANY NAME `D 'S.. 0-"-405 ADDRESS �U2-
CITY '2/0 c IfleAl STATE N"l- ZIP OP-14% (� TEL r 602- 9*,3 jp
FAX 3(y� V-73 CELL � ' 7 3��>4CUEMAIL 'MD.S /v / C. + c U
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