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HomeMy WebLinkAboutBLDG-18-006052 piEp PARC t/ • Y ' 1 .,MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Y , CITY,Tow�YAQrnn()TN f MA OATS n l PERMIT# PI-06/3' S,Z ��^^(1 • JOBSITE ADDRESS, I A Ort);�o r Ln I OWI Jn NER'S NAME� nY. Jrr� n rle r s nn �T OWNERADDRFSS Oa S Yb... o. Dr • 4 Inn JMnJett, tial 'FAX TETE OCCUPANCY TYPE COEREIN.D EDUCATIONAL[ RESIDENTIALiti PRINT 11VT MM cur R7.Y NEW:[ RENOVATION;al REPLACEI ENT:CI PLANS SUBMITTED: YES❑ NO© APPLIANCES 1 FLOORS-. 8511 1 2 3 1 4 6 8 7 • e a 10 11 12 13 14 BOILER .BOOSTER _ NSW. _ O. CONVERSION BURNER SWANst, sa _-- r COOK STOVE • - DIRECT.VENf HEATER ,_ .._ DRYER FIREPLACE FRYOLA7T)R • .- FURNACE • • GENERATOR GRILLE , - . It.. e =' INFRARM HEATER LABORATORY COCKS ave .•.,r•1:41 !I._221,. ,. MAKEUP AIR UNIT ma ass izs:.,14A.:ils.,as., =I 11.:1'l;,LCS! OVEN. POOL HEATER ' ' ROOM I SPACE HEATER ROOFTOP UNIT • ,_ I TEST UNIT HEATER _ UNVENREDROOM HEATER . _ WA TER ITER__.. ._. - ....a a igga alga siiii 1�i a 4 INSURANCE COVERAGE I haver a current Ilapilftv Insurance policy or Its substantial&prelate"Mtt meats the requirements of MGL Ch.142 YES VINO Q I FYOU CIECKED YES,PLEASE EiDICATETHE TYPE OF COVERAGE__,( BY QEGIMIGRE APPROPRIATE BOX BELOW UABILIIY INSURANCE POLICY 1!J OTHER TYPE=awry a • BOND OWNER'S INSURANCE WAIVER I am aware that the Iicetsee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signalise on this permit',portionBrim this requirement. • CHECK ONE ONLY: OWNER 9 AGENT CI SIGNATURE OF OWNER OR AGENT I hnby nay that al of Ms dangly ad-bdcnnafan films ad:antd orerdrsd snarling OS B tarskn ars bus anci .. b • ' • ape Imwiadpe and bid a6plumbu,pwork end tMaperformed under it:permitim.dtaedaappar�onwabeIn-• Ar•T - der M ahnWig s&teas PIu Coda and Chapter 142 of the Smratd taw: 'f ;e PLUMBER-GASFITTERtam 1WeUin mLBr:rip. (LICENSE . ` - • SI TUBE InZi MGFD JP❑ LED LPGI p CORPORATION alit min! PART SHIIPjD4 l LLC L COMPANYNAFAEWevr••nl'srraa Plum*11 e4 ,i ADDRESS; II l.ncii.Sri 4 CITY W.Ynrnvst + t • STATE 111741 21P} Oa67$1 I(5ise 14�3L I • FA 17 o-s7161cE s0%-17iovfcplo ret b ® ro —JP-sr ,-4e-4- I . APR 3u 2013 /�J ) /I 4744f, EPART' E'l 'v 1 .. PC(t 6/99 0X. G!? Fso . 274. /Tn- • 5a' k 50 : Geek _ _