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HomeMy WebLinkAboutBLDG-18-006740 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK V-4•We CITY KJ L Y� elZ47 K MA DATE ©, PERMIT# F "ar/r-ere0 JOBSITE ADDRESS / / fG�- �? , OWNERS N.AMEI4,¢- OWNER ADDRESS TEL FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 11/ CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: LV PLANS SUBMITTED: YES❑ NO APPLIANCES 4 FLOORS-F BEN 1 2 3 4 5 6 7 8 _ 9 10 'I'I 12 '13 14 BOILER --I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER • DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR _ GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN �1 POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER ' OTHER _ I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG .BY CHECKING THE APPROPRIATE BOX BE 01 LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ lop o92018 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage regtiir 42 of they Massachusetts General Laws,and that my signature on this permit application vvalves this requiromeri�. B P RTly�ey:UI V7G • 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 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 provisio f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE#0//7 'IGNATURE MP> J�GF❑ JP❑ JGF❑ LPGI ❑ CORPORATION❑# ( PARTNERSHIP❑# LLC❑#>: COMPANYY, NAME 4-)—9/1-PY ADDRESS / ( Y' CITY v"� N STATE /VW ZIP O d4 G. TEL FAX 61 )_P- 11 ) CELLS 34,7 385T EMAIL g4) ce,LF .041L