HomeMy WebLinkAboutBLDG-19-003602 MASSAC USETTS LF FORM APPLICATION FOR A PE MIT TO PERFORM GAS FITTING WORK
e,•�'ro1 CITY // ---"")1 ` MA DATE O`Z /G /PERMIT� , '00
JOBSITE ADDRESS A 4- 8 \7%rip S .X( it
WNER'S NAME �1 U�1 K ���� L
GOWNER ADDRESS V TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL%
PUNT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES NO❑
APPLIANCES 1 FLOORS-4 BSM 1 2 3 1 5 6 7 8 9 10 11 12 13 14
BOILER —1
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER j
DRYER 1
. i
FIREPLACE
FRYOLATOR
FURNACE
-" GENERATOR
GRILLE
INFRARED HEATER.
i
LABORATORY COCKS
MAKEUP AIR UNIT 1
OVEN i
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST -- . . ... . .. -
UNIT HEATER ___#- .�//
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ❑ NO ❑
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 li ensee does not have the insurance coverage required by Chapter 1E12 of the
• Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT El
J SIGNATURE OF OWNER OR AGENT J
•ii:: 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 comp' nc 'th all Pertinent provision of the
`, Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P- 1
1
PLUMBER-GASFITTER NAME GG r j � 16 /r e LICENSE# OI 9 / SIGNATURE
i JGF CORPORATION #F PARTNERSHIP # LLC #f I
MP � MGF❑ JP❑ ❑ LPCI ❑ ❑ El ❑
COMPANY NAME If9-01 le ADDRESS C9 7 i'`/y/� iv"r
CITY 116 `I 4 f 1 STATE 6 f ZIP D Ei e// T
FAX CELLS— �� .. -5-°7 SEMAIL V �U ( ovs/ {54 , kej` /
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