HomeMy WebLinkAboutBLDG-020-001066 5 r2t-i? Oxvi
{— ,. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`> CITY \l/ uN�:��" _ MA DATE /26/! - PERMIT#%1446 2°10O,0
JOBSITE ADDRESS 3Es&:-v-A i/0Ole be- OWNERS NAME )C30 t2G L4_
OWNER ADDRESS TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
)AFT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
•
APPLIANCES 71. FLOORS-4 BSMM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ___1
BOOSTER I
CONVERSION BURNER
COOK STOVE _
DIRECT VENT HEATER _ I
DRYER
i
FIREPLACE
FRYOLATOR
FURNACE
I ,„ , _
GENERATOR
GRILLE I f
INFRARED HEATER _
LABORATORY COCKS C E 1 ".
MAKEUP AIR UNIT
OVEN
POOL HEATER Pr
ROOM I SPACE HEATER __
ROOF TOP UNIT �` �_�'
TEST -
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES la NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLIC' OTHER TYPE INDEMNITY ❑ i
BOND ❑ I
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
f Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
.1, I hereby certify that all of the details and information I have submitted or entered regarding this application are true an. . -• . ;best of my knowledge
`— and that all plumbing work and installations performed under the permit issued for this application will be in co . .I''th ai t provision of the
`` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,��1
`1
PLUMBER-GASFI I I EP,NAMESV\)C�1/�rs-c.Q6— LICENSE# 1, C:)9 / SI .,-TURE
MFtZ MGF❑ �yJP ❑ JGF❑ LPGI[I CORPORATION K4 -- L(g PARTNERSHIP❑# LLC El#
COMFAI�IY NAME T 0‘ A 7' ` `v"t\it.` J- C ADDRESS l 3R —LkAs.PC-udC�JC& CO Ry
CITY %/2 s STATE . ZIP d.1 C.3 I TEL ? 9 ')9 1),A,- L S
FAX CELL EMAILLkCekS4&t`Lksi *L"-t.\ i,t1C>�c�CO C 1-.v
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