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HomeMy WebLinkAboutBLDG-25-506 <2, F ED SEP 17 2025 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PEIFORM GAS FITTING WORK = CITY:% MA DATE:9�7e.ZA J PERMIT# fr— JOBSITEADDRESSa�,d/..�,F /7" OWNER'S NAME;/ � �d�S L`�✓ ' G OWNER ADDRESSL//��j/ C vd 1 TEL: `36/oj" FAX: TP OR OCCUPANCY TYPE' - COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIALP2— T CLEARLY NEW:0.7 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO❑ APPLIANCES? FLOOR—. Burnt 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 W LABORATORY COCK k MAKEUP AIR UNIT Q OVEN POOL HEATER ROOM ISPACE HEATER J ROOF TOP UNIT ' TEST UNIT HEATER t L UNVENTED ROOM HEATER WATER HEATER J r INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0 If you have checked yo,please Indicate the type of coverage by chec'g 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 CHECK ONE ONLY: OWNER 0 AGENT❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate..the best of m Knowledge end that all plumbing work and installations performed under the permit issued for Hs application will be �� P:ri11.t provision of the Massachusetts State Plumbing Code and Chapter 2 of the General Laws. 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