HomeMy WebLinkAboutBLDG-25-159 MASSACHrr��SETTS UNIFORM APPLICATION FOR A P RMI TO PERFORM GAS FITTING yy0�
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CITY YL42165 Lf OF
mac/ I /J MA DATE m2j PERMIT# GLDG-ac-jf '
JOBSITE ADDRESS v l e T 2 q3 OWNER'S NAME
G OWNER ADDRESS
TYPE OR TEL FAX
Y .t. OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL —
CLEARLY NEW:❑ RENOVATION:
❑ REPLACEMENT:❑ PLANS SUBMITTED: YES
trio APPLIANCES 1 FLOORS—r OEM 1 2 3 4 ❑
BOILERL inn == 2 3 s 10 11 1= 1_
BOOSTER
CONVERSION BURNER, Mill
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COOK STOVE
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DIRECT VENT FIEATER
1
DRYER
FIREPLACE
FRYOLATOR -
FURNACE E MEMO
GENERATOR
II
GRILLE
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LABORATORY •
MAIUP AIR UNIT
MM1
OVEN
PO
L HEATER • _—ROOM/SPACE HEATER
rF TOP UNIT
OTHER
INSURANCE o
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
III
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I have a current liability insurance policy or its substantial equivalent COVERAGE
nt which meets the requirements of MGL Ch.142 YES 0 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND 0
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.
SIGNATURE OF OWNER,OR AGENT CHECK ONE ONLY: OWNER❑ AGENT 0
,-, 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 compliance with Pertinent provision of the
'Q.) Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-r FITTE ME LICENSE# t�//�// SIGNATURE
MP MGF JP �JG/F OM-MAW
❑ CORPORATION 0 ti PARTNERSHIP # LLr P#
COMPANY( ��E�/ g���ri � a/,�7_Lc E_OS 2 t�� /� r-1��✓/V /r�//�fL
CITY y/`Y1`/V 1O t2 l -0 STATE 72IIp `6 7 , 1 TEL (�JJg 5hO 3
FAX CELL t A�l.C�1/14.6 m p 6 egp(44(1
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