HomeMy WebLinkAboutBLDG-19-003623 #16 V
~� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
I "? vAp6 CITY Mo'JA-h MP, DATE BI2/4q/A. PERMIT#/ 'der-M-0o %
JOBSITE ADDRESS A`iS KW Q - V.tii 4 AO OWNERS NAME f iiik K/,( 2QOA'llia-0
GOWNER ADDRESS X LI S TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL[� EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PP PLANS SUBMITTED: YES❑ NO u
APPLIANCES 1 FLOORS--I BSM 1 2 3 1 5 6 7 8 9 10 11 12 13 14
BOILER 7
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER I
DRYER
i
FIREPLACE
FRYOLATOR - I
FURNACE 1
GENERATOR _I
GRILLE
INFRARED HEATER —�
LABORATORY COCKS —�
MAKEUP AIR UNIT
OVEN i
POOL HEATER • 1
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST 41,- .� i en .
UNIT HEATER l _ _
UNVENTED ROOM HEATER
WATER HEATER
OTHER i
.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [( O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
1 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. I
-1 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 and accurate ti • .-- . -- knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in compliance -• - -ertinent provision if the
Massachusetts State Plumbing Code and Chapter of the General Laws.
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PLUMBER-GASFITTER NAME VI 6i(,0 s+lv i LICENSE#3/3%--a SIGNATURE
MP ❑ MGF❑ JPI�J/GGF❑ LPGI El . CORPORATION❑#F PARTNERSHIP❑#t , LLC❑#
COMPANY NAME Silv4 ii411)l'/6�I¢•QA)1Iij ADDRESS Dss sLbbLQ y L44,,e
CITY 1/ A.u.v i S — STATE/nA ZIP 02 6 O/ TEL J
FAX CELL! 703(>O/ 76 EMAIL vita iL i 0A4 GA g I L
4-.4, _ C„ 1
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