HomeMy WebLinkAboutBLDG-17-003188 T.: �°
MASSACHUSETTS UNIFORM APPLICATION FORA PERIAIT TO PERFORM GAS FITTING WORK
-_.1-r# CITY C. 70:nr c:5bhMA DATE t PERMIT#1&f /7-.O
^G JOBSITE ADDRESS 471, b LC A E- w J t'.. OWNER'S NAME ..Teo4 0 he--
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OWNER ADDRESS 54"`'.c-- TEL 140-0a14' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL F2.----
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:®— PLANS SUBMITTED: YES❑ NO❑
_APPLIANCES 7 FLOORS-. 8SM 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
FURNACEACE
r
GENERATOR
GRILLE / - 1
INFRARED HEATER f/
LABORATORY COCKS ..11
MAKEUP AIR UNIT - K
� G`Qi ` ,iV
OVEN `
POOL HEATER ' � _, nu,
,.
ROOM!SPACE HEATER O�C ,5
ROOF TOP UNIT \ `' N* ___
TEST ,}-�
UNIT HEATER eu'�j'
UNVENTED ROOM HEATER
WATER HEATER
OTHER •
INSURANCE COVERAGE ��
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 6140 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILRY INSURANCE POLICY 2?-***-- 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 applicationiwa v se this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that a0 of the detaes and idornatlon I have submitted or entered regarding this application are hue to the best of my
kn edge
rn
and that all plumbing woend iisfallatione performed under the permit issued for this application will be F Pertinent p ovist
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTERNIME A' 4114" LICENSE# 901r SIGNATURE
MP WC IGF❑ JP❑ J.GF❑ LPG'❑ CORPORATION 170119 PARTNERSHIP❑# LLC❑#
COMPANY NAME a C/*tac n t ADDRESS 9 PYfict en /0cle
CITY 6. y/it add, - f STATE J1461 ZIP 4,1-(64f TEL -
FAX �SOOfgone' CELL,j� 7)6- �Jf'36 EMAIL c5'* £ lty1C co 4t 44171cc(aw7
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