HomeMy WebLinkAboutG-18-2689 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
"-Mt CITY y yfc v'k4kc o (A IMA DATE N. 1' \ 1 1 PERMIT#4/l 6t t?
JOBSITE ADDRESS LI Va iZ 0 ti OWNER'S NAME`I6(C C q h o ct✓�
GOWNER ADDRESS TEIJ IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL Q RESIDENTIAL2j
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CLEARLY NEW:Q RENOVATION: ►^4 REPLACEMENT:0 PLANS SUBMITTED: YES Q NOM.
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER 5155.5 • _ _ ,
CONVERSION BURNER f *t. *SRa
COOK STOVE
DIRECT VENT HEATER 1110111MIlils: , jMIIII sintostipaimptsiorain
DRYER ' ; las Mil Nita SSS
FIREPLACE f'5; aMEM_MKs'
FRYOLATOR
GENERATOR _sass 5
GRILLE
INFRARED HEAT C EII1IIIIIIREI
LABORATORY COCKS
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ROOM!SPACE HEATER 55 55 5.a a s a r; x,A,,nSIMISOPPI
ROOF TOP UNIT 111111111111S Stsari I/ n'n ) ;
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UNIT � i
UNVENTE �ROOM HEATER �i5' I
. • Sims S5E'11IeitMlllIS101111.AMMalin NM1*15
OTHER SIMPKIMM111111111.11.1 SS 111164101.1.0.111soss I:
0011111111111111111011111SSISS=WS.1.111111111111111111S
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ailinS IS SS IS 111.1111111111111111,00110141110011.1111111111IS SS
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES !:<. NO Ej
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY`(t OTHER TYPE INDEMNITY 0 BOND
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 Q AGENT Q
SIGNATURE OF OWNER OR AGENT
1 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 pent Issued for this application will be in lance with II di nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME on/I//X twat UCENSE#11(,3{, IGNATURE
MP Da MCF❑ tip Q JGF Q LPGI Q CORPORATION Q# PARTNERSHIP041 'LLC Q#
COMPANY NAME:WA r fl/,Ul'fe//JrNf fA•r/,{/(-1 J ADDRESS 6r2-,(/FUS P3A.Cim) £0,
CITY fit'//J/S Era r J STATE rZIP 0 3 j� TEL ,SOK- 3 Fs-9 7sS-
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