HomeMy WebLinkAboutBLDG-18-007035 ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1` L. CITY I.:7,1-Fro0"Vtltil--- -- i MA DATEQ2�tr!
r PERMIT#aper/1r'GO 7005-
JOBSITEADDRESS'__:61 15q l�-a� PqW- IOWNER'S NAME - - -~-
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OWNERADDRESS {MAWT..-__.._ --. -+ _v1TELI �. (cb: SFAXL _..-_..._..__.I
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TYPE OR OCCUPANCYTYPE COMMERCIAL , ' EDUCATIONAL
PRINT ., RESIDENTIAL I V
CLEARLY NEW:l/ RENOVATION:Li REPLACEMENT:ELI PLANS SUBMITTED: YES ENO?
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 to 11 12 13 14
BOILER
BOOSTER — — —
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE I ' I .i
$ M1 - L
GENERATOR - -FRYOLATOR
II
GRILLE
INFRARED HEATER -
LABORATORY COCKS
MAKEUP AIR UNIT ` .f , _ �._ -
OVEN 1 t I
POOL HEATER _I
�4 1 �
I
ROOM/SPACE HEATER -`"- ' -
ROOF TOP UNIT - _ i -- -„ _ _ I 'i L , -t-. I_ - ,i
TEST -` i,- - . ii - - a -- ;i LL
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UNIT HEATER '�
UNVENTED
W TEAR HEATER
M HEATER
_OTH
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INSU
ANCE
GE
I have a current liability insurance policy or Its substantial equivalent ent whi h meets the requirements of MGL Ch.142 YESO L
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OFCOI/EWE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [-; OTHER TYPE INDEMNITY IT..I BOND tEl
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.
3 SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER f; AGENT El
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 i�compliance
a with I Pe Inert provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME' -`
_ / i�}�V' w0.dG — (LICENSE#�'1,� SIGNATURE
MP _. MGF;. , JP:i_ j JGFt.j LPGIII ._ i CORPORATION`# --..__. IPARTNERSHIP #j --_,-"i i ._....'—._'
f - I L.� LLC(_,#�_
COMPANY NAMEet nn CD.4.I Yl 1.t(fGViC Ifi:P4 DORESS '.._ i _oii9l n -aIT—7 11111~-__`__I
CITY '.N�as41 _ — ; STATE i L\?ZIPI021Ii2, 9 -1TELEjIg--y7--crn�' 1
FAX(" --�'7_1CELL'( TEMAILLI of&P P JP att/12,-•-0.Tb-Y les-vin
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