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HomeMy WebLinkAboutBLDG-24-572 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY LO Ia1Ma3 MA DATE 1-a541 PERMIT#fli-OE'"11'572- JOBSITE ADDRESS 32... Cowl S}. OWNER'S NAME t+Cau / GOWNER ADDRESS 3 do- C-41 A TEL 5'63 1-554A FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Er PLANS SUBMITTED:YES 0 NO[� APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT 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 LIABILITY INSURANCE POLICY U✓ 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. CHECK ONE ONLY: OWNER 0 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /) //0005— PLUMBER-GASFITTER NAME T rk tl LICENSE#3, j- /qqq�_/ii SIGNATURE MP I2 MGF 0 JP By JGF❑ LPPPGII❑ CORPORATION 0# PARTNERSHIP 0# LLC❑# COMPANYI NAME -I'PIL$0hn�' t#mtt9 tGP.S g ADDRESS 17 Par�U] CITY \l� lJ J STATE C I TEL 44`�o"G.13 FAX CELL EMAIL !k(�Mirto,ei 02.1.1( rA &c