HomeMy WebLinkAboutBLDG-24-202 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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_:r CITY 3vo}'r�itr1cvrN MA DATE /Hil'Re(r( LS2d24 PERMIT# gLOG-24-202
JOBSITE ADDRESS 2O 62.w r?.-Kd./FfZ 57 OWNERS N.AME._I�U/fi
GOWNER ADDRESS QD l'I7/4Y1:( /PR,yjfieji,1GM ' r-TEL
TYPE OR —/ FAX
PRINTOCCUPANCY TYPE COMMERCIAL tl� EDUCATIOl AL ElRESIDENTIAL El
CLEARLY NEW:/RENOVATION:0 REPLACEMENT:❑
PLANS SUBMITTED:YES❑ NO❑
APPLIANCES-1 FLOORS BSM 1 2 2 4 5 6 7 B 9 10 11 1.
BOILER 13 ,
BOOSTER
CONVERSION BURNER �_
COOK STOVE �_
DIRECT VENT HEATER _ - �—
DRYER - —
FIREPLACE
FRYDLATOR _
FURNACE
GENERATOR - _
GRILLE - -
INFRARED HEATER - _
LABORATORY COCKS
c-f' OMAKEUP AIR UNIT at -EI V 1
V POOL HEATER - -
ROOM!SPACE HEATER - - - -` - 4M 2 5 2024
ROOF TOP UNIT
TEST ... .� ..... ...._. .._... .. _ FS IP LUIIV'L[rARTne .i
UNIT HEATER
UNVENTED ROOM HEATER -
r WATER HEATER
Z OTHER
_
cy)
INSURANCE COVERAGE T ��
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. YES [ NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [/ 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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El AGENT ❑
ti� 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 wi Pert'
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. pro Ion re
PLUMBER-GASFITTER NAME LICENSE# 3Is -7 S NATURE
MP❑ MGF❑ JP EKJGF❑ LPGI❑ CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME 17W'ftt-<`; PGu--(i3rA/6 1 H64TI,J6 ADDRESS 26 J30A/RJ6 L04,J/E
CITY l{/ T ynei.pum STATE P4 ZIP 02673 TEL 77'f-8.3( -2534
FAX CELL 774-5?36-2534 EMAIL king e-7-xcPLvit/tea'@G,r44/4.dorsi
c:t� Licas 90 —
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