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HomeMy WebLinkAboutBLDG-23-9341 h0,vp __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 11 DATE o CITYf3 Z3- �3y1 � � MAG1/2--/-/ Z�3 PERMIT* ��G� JOBSIT ADDRESS / At 116`%/4 rZ OWNER'S NAME OWNER ADDRESS TEL FAX TYPE O t OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINTT CLEARLY NEW:❑ RENOVATION —REPLACEMENT:❑ 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 1 ; FIREPLACE _ FRYOLATOR I FURNACE 1 ` GENERATOR _ GRILLE -INFRARED HEATER LABORATORY COCKS , MAKEUP AIR UNIT OVEN POOL HEATER • ROOM ISPACE HEATER ' ROOF TOP UNIT TEST _ .._.._ _._.. F Aff UNIT HEATER UNVENTED ROOM HEATER • WATER HEATER 2 1 423 OTHER dui uiNG � _ �.t L)r r kl kd MI F I _— INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YE*1 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY 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 0 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 accurate to the best of my knowledge `s and that all plumbing work and installations performed under the permit issued for this application will be in com • th all Pe • vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -e-/ J PLUMBER-GASFITTER NAME eke't �=1 Y.-Id. LICENSE 6, IG RE MP❑ MGF❑ JP)K JGF❑ LPGI❑ CORPORATION❑# PARTN RSHIP❑#fit JJ L/LC❑# COMPANY N ME ADDRESS /r2 G� r 34X 7 L/ CITY tI14)Id STATE IA14 ZIP (12-6,- ! TEL >7 Y + q!02 FAX CELL EMAIL C�fii �©�✓ fi4rill CaaJiyh prbiDr)ma-) /, cow rs va H G I W1 r [O w Cj a t w z- . . . ] I 2 co Ch O 0.1 h- U =.t d U3 t- � Q pe Cf� w C 0 - 1