HomeMy WebLinkAboutBLDG-19-003488 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
MN:73
�-,,,r CITY So a iC ,f}R_M04.i 04)46Y-M?. DATE j,>-/-7 l i PERMIT# "60.99i4
JOBSITE ADDRESS 4/08 No27C- Mit l.J St• OWNERS NAME fjic,(j9GZ. cgoW
dEy
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL hr
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO iSr. 1
I
APPLIANCES- FLOORS-- BSM 1 ? 3 4 5 6 7 8 9 10 11 12 13 14 i
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER —�
i
FIREPLACE
FRYOLATOR -
FURNACE '
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT 1
OVEN
POOL HEATER • _ ,
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST - . f ��j��`
UNIT HEATER
UNVENTED ROOM HEATER -
WATER HEATER _
OTHER -____.-
-
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES.5P_11NO ❑
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.
1
CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1
SIGNATURE OF OWNER OR AGENT
.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 1
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pe ' ent provi ion of the
Massachusetts State Plumbing Code and Chapter 142OO
the General Law . (*-07,4- -
LEI
PLUMBER-GASFITTER NAME 'Moir)4J 1.1ay.61 LICENSE# /4A-aq SIGNA RE
MP MGF❑ J,F JGF`❑ LPG' ❑ CORPORATION Q # S'7 L PARTNERSHIP❑# LLC❑#
COMPANY NAME /l � - f1'67T'1vG' Y-Cat(Ng--"" ADDRESS 0 ineLisr.1- ,a-id-6---
CITY Y/Q fi /La 0 u STATE Mil---
ZIP tea C -2a— TEL <8. '23 7-0001
FAX �� CELL58- 7?.-- g//3 EMAIL C./? (Q1 �