HomeMy WebLinkAboutBLDG-17-00180 I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�,tif CITY Yal(t1-4c9 17 OMA DATEI , "'—/ C PERMIT# I✓Ap6'""�7�Od/7(
JOBSITE ADDRESS ►2 "r ru i'Na 4 Q0 OWNER'S NAME wo{e_y M u f e. I ck j
GOWNER ADDRESS 12 T Ma.vl. Q,n TEL cj'7 3 '7 yr/ ri 3Z FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL.
PRINT
CLEARLY NEW:Fr RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES LI NO❑
APPLIANCES Li FLOORS' I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER - tri -..
BOOSTER _ 8__
CONVERSION BURNER '
COOK STOVE
DIRECT VENT HEATER 1
DRYER
FIREPLACE 1
FRYOLATOR
FURNACE f}Tt rC. A/j [ 1. ,
GENERATOR 4
GRILLE k
INFRARED HEATER —' `
LABORATORY COCKS
MAKEUP AIR UNIT I ti _______1_
OVEN
POOL HEATER
ROOM/SPACE HEATER 4_ .. I. _.
, i j,, ��,
ROOF TOP UNIT
TEST T tr
UNIT HEATER u 4
UNVENTED ROOM HEATER ir----
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES VNO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V 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 d rate t t st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli n "h aIFP t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Jcc,(0 Ve l 0.5 y0GZ— —1 LICENSE# 31)1 Z SIGNATURE
MP MGF JP t/ JGF LPGI 7 CORPORATION # PARTNERSHIP # LLC #j I
COMPANY NAME:J q,cc del n5 0 G Z_. :ADDRESS /G y 19 a 54 n 7 (a 14, ay
CITY go(LA),L 1
1 STATE I M/1- ZIP 0 2 C e fs TEL `7 ri L( 01 L 4,C,Z/c/
FAX CELL EMAIL E____JCI,rrO 61, y'abo J
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