HomeMy WebLinkAboutBLDG-24-788 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
AS CITY 4f/y)leff MA DA PERMIT#13t-0G-t5
JOBSITE ADDRESS 74 13I',Di9Z> 7 p 9�" OWNER'S NAME 4NAj% S p4dy4,
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:g RENOVATION:25 REPLACEMENT:0 PLANS SUBMITTED:YES® NO 0
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
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 R E C E I VV
UNVENTED ROOM HEATER
WATER HEATER / 2 R 2024
•
OTHER [DEC
B JILDING DE�AH I MENT
of INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Z NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Z 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 t . .a at- • h best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn i. -wit al`'erti r-nt provision of the
Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. '/jL `—ram
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PLUMBER-GASFITTER NAME A U v LICENSEE // SIGNATURE
MP 0 MGF 0PP1U1
P 0 JGF 0 LPGI 0 C ORATION 0# PARTNERSHIP # LL 0#
COMPANY NAME VACP y .{�/—Ir ADDRESS .56 Pr �/
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CITY / � .ypgSTATE �' ZIP TEL/�/`��9
FAX CELL,, i ! 070 I/ EMAIL P OGCt7 ? fri- 1 0 Grac1