HomeMy WebLinkAboutBLDG-23-9335 Au-e: P RC L
_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�au_a MA DATE MIN PERMIT#
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JOBSITE ADDRESS _Q_ (OWNER'S NAME ..1141ibil.a A I Q. g ,.0 it 1
G OWNER ADDRESS -7 3 OE ItiaigNAMI FAXL-____J
TYPE OR OCCUPANCY TYPE NCOMMERCIALQ EDUCATIONAL Q RESIDENTIAL -
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CLEARLY NEW:Q RENOVATION:Q REPLACEMENT:[ PLANS SUBMITTED: YES NOW
APPLIANCES Z FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 13 14 m(
BOILER W� --f 11 SIII
BOOSTER IM r s
CONVERSION EURNER A 'I
DIRECT VENT HEAT
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COOK STOVE � iONN ._
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.. fit_ 11 s
DRYER �_- i
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FIREPLACE 1111 i� _
—FRYOLATOR 1( j
FURNACEINIMILISMINII I �I
GENERATOR � - ' ( „f GRILLE " i ( r----,--
LABORATORY COCKS I —
INFRARED HEATER _ _
MAKE ` .._...ri .
MAKEUP AIR UNIT ! 1E J
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POOL HEATER 0 .
ROOM/SPACE'EATER .J (�'`' 3
ROOF TOP UNIT I' ""
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UNVENTED ROOM HEATER1110411111MONErnitalit-
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WATER HEATER._ — — ( l I ��
OTHER I
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(j Y� ' INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES El NO Q
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY C1I BOND LI
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 LI AGENT Lit
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 of t_
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. __(2- t"inJ(���
PLUMBER-GASFITTER NAME �°L,_ r..,�.._ LICENSE#grill ( d
SIGNATURE
MP Q MGF ElJP Cg JGF Q LPGI I j CORPORA PARTNERSHIP Q# #LLC[.l#C+TION Q# _
COMPANY NAME: C 1 IAP I--c� - -_I ADDRESS ��!1_,_.._ I✓1e
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1'� 5 STATE I !ZlP . TEL 7 I j Z.T--1
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FAX 4- CELL —JEMANOI. -iN , N.t .f i ...a.. .4/4'1(- .'.. C ... -
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