HomeMy WebLinkAboutBLDG-23-8803 r
5-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY '1Aft 01/4(^ l OR t MA DATED S/2 9/2 i PERMIT# Z3 grr73
JOBSITE ADDRESS a9 f S1 OWNER'S NAME d'rnrl rtl C Ak o
OWNER ADDRESS ei FI Si" 1 a/a (X \p OQfrEL roe-7/ -7O65 - FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED:YES 0 NO❑
APPLIANCES 7 FLOORS UM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I _
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 0
I F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGEAG BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY [� 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❑
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 orate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian ertlnent pro'' of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Lij
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP® MGF 0 yyJPP�❑ JGF❑ LPG!❑ CORPORATION❑# PPRRTNE. HIP❑# p LLC❑#
COMPANY NAME 1^� k— -IA I l D ADDRESS I 7 ILAY4' Fr-°9 A v"
CITY K 91� C e S /�-� STATE �m Lst.. ZIP 0 I '6 0 TEL
FAX CELL 0 d, 41 I°9( )EMAIL
Or
I
I
E-4
G.
4
27,
O.
E7^+
f
Dr)
f �
n
G',!
C)
0 2
W
f �
F-
cf:
LU.. .
cia
a U
1
Cry
1
C
LU
I E'- U-
1
Cf.)
0
0
w�c
r )
71
I (�
rep
4
C�1
C)