HomeMy WebLinkAboutBLDG-19-006001 ' -- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
` k=.; CITY /47rmacf// MA DATE PERMIT# nLMr / 7-0a iI
JOBSITE ADDRESS/ ,EV t✓,I ee0 Dv OWNERS NAME 4 rt C1�-'i S i4cyd
GOWNER ADDRESS �Q -ye. V TEL(7!? sr/4 4 33 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL '
PRINT
CLEARLY NEW:X] RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES T FLOORS- BEM 1 2 3 4 5 6 7 8 9 10 1'1 12 13 I 14
BOILER
BOOSTER _ j
CONVERSION BURNER
COOK STOVE I
DIRECT VENT HEATER --i
DRYER 1
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR .-.__....—..-._ ,
GRILLE _- E 1 V E i
INFRARED HEATER I
LABORATORY COCKS I
.
MAKEUP AIR UNIT 1 AF R 2 3 HA -
OVEN .9 J 1
POOL HEATER j" -NT
ROOM I SPACE HEATER — "--- I
ROOF TOP UNIT
TEST ...
UNIT HEATER _
UNVENTED ROOM HEATER
WATER HEATER
OTHER
,
INSURANCE COVERAGE
I have a current liability insurance policy or it substantial equivalent which meets the requirements of MGL.Ch.142 YES X 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 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.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT J
3,6•, 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 compliances wiith�all Pertinent;
provision of the
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i�! a(
PLUMBER-GASFITTER NAME LICENSE#07a a3 y SIGNATURE
MP ❑ MGF❑ JP [i JGF❑ LPGI ❑ - CORPORATION❑# PARTNERSHIP❑# LLC❑#i# I
COMPANY NAME L. 1:Di T11im' ���� 5 ADDRESS ���-^ b ' �
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CITY 2,4,-PS"'`s A ///S STATE,X1l ZIP D 4,V'//ar TEL 2 7 Z' y,7 , jf/ I
FAX CELL EMAIL vi/gTrv/We?4 3 lam' C'.,,C€s ,,,,,--7
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