HomeMy WebLinkAboutBLDG-24-601 P
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`w
tk a' CITY W-y6(Mtrukh MA DATE t6-04- PERMITS Qt-bCv-21" tool
JOBSITEADDRESS F. (ire Gired#yorM RG ' OWNERS NAME rim C ho/QsLa
OWNER ADDRESS SQ/n e' TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL®-
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO in
APPLIANCES-1 FLOORS BEM 1 2 3 A 5 6 7 8 9 10 11 12 13 1e
BOILER f
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER n
LABORATORY COCKS R C
MAKEUP AIR UNIT
POOL HEATER OVEN
OCT Q9%�24
ROOM I SPACE HEATER ROOF TOP UNIT BUI ntN,DEPARTMENT
BY
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 MGL.Ch.142 YES ®NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 54 OTHER TYPE INDEMNITY 0 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.
} CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
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 I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# aa.7 SS I SIGNATURE
MP❑ MGF❑ JP[gl, JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Kant 1<oearaa rn ADDRESS 39 Monervl6V Rat
CITY 5-yarm- STATE rn4 Zip aa664
TEL
FAX CELL 5-6$-6$S S6S'6 EMAIL j kent C P y6 koo•corn,
—
1 .
H�-I
1 (obi
r.
w.c
c
I
l
�` CZ
0: co
1
r H
H
4
PA
1 c rr>
1 ..
L
y Q
G)
1a..
Gty
1 T LB
I � �
1 �
I �
G1-1
I �
1