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HomeMy WebLinkAboutBLDG-19-002379 /114.0 /FARC 6./ _MASSACHUSETTS UNIFORM APPLJCATION FOR A PERMIT TO PERFORM GAS FITTING WORK EL • CITY 1Tavt� yAa o ( MA DATE! 1 Dik/Ik (PERMIT#fid--0bW-GYToP • JOBSTTEADDRESS! I h &I M /•n , IOWNER'S NAME f \►I m K(?IIS/ f G OWNER ADDRESS I • • 1m4774 Alp•OL44 IFAXS TYPE P TOR OCCUPANCY TYPE COMMERCIAL{j WUCATIONALU RESIDEN11AL01 CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:NZ PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 7 FLOORS-. - 1 2 3 4 5 $ 7 • 8 9 10 11 12 13 14 BOILER 4% / J BOOSTER a' SS WS,-1 1 .' _ — CONVERSION CONVERSION BURNER . a t __ sea S;' '_ ` _ COOK STOVE . DI RECT.VENT HEATER .- DRYER _i ..! FIREPLACE — FRYOLATOR - FURNACE • GENERATOR — - i _ i _ _ . GRILLE g.41 . P , ni , _ ., ' INFRARED HEATER LABORATORY TCSll:{1{ 71 ru.n `1.ih. , •.'+ MAKEUP AIR UNIT y, * : , I ' • • • nct NO. . In . OVEN' yu 1^ Alt is ' s •y i=; LL r POOL HEATER ' r ' WlnONe1 `riled a ROOM I SPACE HEATER ROOF TDP UNIT • IL II .n UNIT HEATER UNVEN FED ROOM HEATER sog Immo"row as lin iinrosir MO sir ololoot as 1 o I IF ® R a INSURANCE COVERAGE �,/ I have a current liability Insurance policy or Its substantial equivalent which meets the requimments of MGL Ch.142 YES (�NO 0 IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COZGE BY CHECKING THE APPROPRIATE BOX BELOW UABMY INSURANCE POUCY 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 hpplcation waives this requirement • CHECK ONE ONLY: OWNER I] AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby cert'that at at the dotage and I Jarman I have submitted or entered regarding this[(Madan are hue and accurate b e bast of my knowledge and that ea pkrn64q work end Instaaa5ars performed=lathe permit Issued for fhb application wit be In compliance 'a - - purvtsinn at the k State Plumbing Code and Chapter 142�Arne General Laws_ '-9/•i/// - PLUMBER-GASH i i ttt NAME 11(e4/;r, m / ,I(C r-:JP. I LICENSE • Q ` �SIGNATURE UP MGFQ JP JGF©11 LPGIQ CORPORATION(h# a • . • G PARTNERSHIP 0/4 (LLCLam#�: COMPANY NAME4 nlncBr;CLP1um{umc} swirlADDRESSI 1I fiinatrSe4. 174k •• ` t • CITY W. 1/4/nrrAnt..-1'� • smATE rim ZIP 0.24.-73 Fs t EI I 1� (L'14 1 • FAX 'Sof)Tao-G785iCE4Sok 3G4-37d41EMAILI k/VnCID b 6 Cr)mCA54 t' I 2 192010 L. � BUILDING DEPARTMENT •