HomeMy WebLinkAboutBLDG-19-003188 4;4i ,'��/ Poi 'r� 3o73 04,
"`� MASSACHUSETTS Ut4IFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I
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CITY LI/• ✓era'i�m u✓ /lam' MA DATE PERMIT#`�/-a7/ Ci-:''V iT
JOBSITE ADDRESS,/y.. Si,.-a,.., �.oi< ?D OWNERS NAME AI....� OG it)t
OWNER ADDRESS 5 i_>> L-- TEL-. %-3~<I/-c' 561AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Pk PLANS SUBMITTED: YES❑ NO k
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APPLIANCES T FLOORS--' BEM 1 2 3 A 5 6 7 ° 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE —Pe--,
DIRECT VENT HEATER
DRYER _ _
FIREPLACE
FRYOLATOR _
FURNACE
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GENERATOR
GRILLE
INFRARED HEATER
{ LABORATORY COCKS _ •
MAKEUP AIR UNIT
OVEN y
POOL HEATER
ROOM I SPACE HEATER _ -'
ROOF TOP UNIT
ITEST .._ . . . __ .- . .__.. .- ---
UNIT HEATER I _
UN VENTED ROOM HEATER I_ _
WATER HEATER
'L 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 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
i. 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
. v,d, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate t.the best of my knowledge
i and that all plumbing work and installations performed under the permit Issued for this application will be in corn lance with a'7 ' $nA.�.►AM;in of the
, - Massachusetts State Plumbing Code and Chapter 1422 of the General Laws. '�` ff LIB_.
PLUMBER-GASFITTER NAME m Chblel It) kit . UCENSE#_36 2 9a SIGNATURE
MP❑ MGF❑ JP A JGF❑ LPG!❑ CORPORATION 0# PARTNERSHIP 0# /LLC[7]#
COMPANY NAME ADDRESS Oc Ze•:( es b. * l i"i- G4J4
CfY/ ieiti1J 1 iij4) 4
- STATE/ . ZIP e927QI TEL 7?V i172760
FAX CELL EMAIL7 )m(&E Sc a , @►"o j ;/,Coi—
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T 'd T858T658O T+ :Oil, saidv4S :WOUA Wd 95 :£ 8TOZ/ZT/TT