HomeMy WebLinkAboutBLDG-19-006614 TMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY (t&t yv\�� MA DATE' pS f I/ 14 I PERMIT# r /*I7-0 4'&7�
JOBSITE ADDRESS 3a Sp pc' 5pcA�u WNER'S NAME �ev•Io-}rm e,s,,,,n ,,h i
GOWNER ADDRESS 3a Sot c34 0( Ste, TEL 77'-j aiA f)I,JFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW: RENOVATION:RI REPLACEMENT:. PLANS SUBMITTED: YES[J NO VS
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ter
BOOSTER
NEE - ill
CONVERSION BURNER 121 MIN
COOK STOVE -NI
DIRECT VENT HEATER .11111111...1—�___®MI= MIMI
DRYER
FIREPLACE NM MIN
FRYOLATOR Imo _ _®111111M MR 11111111111111Kimit
FLIRNA E , e
GENERATOR
=II . , Plei MN
GRILLE1111111
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INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _ 1 i
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATERII UPUM
WATER HEATER II
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OTHER _MEN®MI IM'�
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NE Mill OM MIN MINI MIN MI KM Milt.aim
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES /I NO n
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ( L 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.
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 compnce with all Pe nent p vision the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P
PLUMBER-GASFITTER NAME vt 6,,,C �j LICENSE# JO,j" SIGNATURE
MP MGF L JP❑ JGF 0 LPGI 0 CORPORATION ri#I PARTNERSHIP: # ! LLC #r..
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COMPANY NAME: I ADDRESS / 9p Jn'V ArH A N5 YV A\/
CITY 5 -Eiv.. -1�k_ STATEr—+ZIP OZ.-Cy_7t 1TELrs Q 0 • f .
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FAX CELLL EMAIL Pic/ 10 (0 A/ `r AS Is\� �/ jgc
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