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HomeMy WebLinkAboutG-19-3067 51) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'r z1n4f; y igi 1t CITY avw,....C./--- MA DATE 0/E JPERMIT#S%VO-00J9 /7 JO8SITEADDRESS f`• n UCLLC -JOWNER'SNAME MI �` U GOWNER ADDRESS I She-- TEL cc,t. &o -r) ,IFAX - TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL© PRINT CLEARLY NEW:0 RENOVATION:© REPLACEMENT: PLANS SUBMITTED: YESD NOD APPLIANCES? FLOORS-' BSM 1 2 3 4 6 6 7 8 9 to 11 12 13 14 1 1 BOOSTER 0/11111/11G11111..I111�II1W11I_iiIrril�I iii l i fillIAI,.IIlla1r1101i�1MA ltiput[IIiII emIl CONVERSION BURNER 1 111111x,( 1111 011�OWSKI INSIO NO i1 11All!I101!SlI COOK STOVE SIJPlSllllf, , : IM S DIRECT VENT HEATER :IM1I I a S(MM�li fa''M i 1 111 DRYER I� FIREPLACE FRYOLATORI1f1� 11U�1 11 GENERATOR alili l ( iII�' ill GI MJII ;G I f i i11 all 001101�f1 FURNACE ��. GRILLE -ir INFRARED HEATER 11 JI 5Z!!IU131 LABORATORY COCKS SSSSIlr M11.M1MM11.1111 11d11I iii I5;0M11a1itil 1 MAKEUP AIR UNIT MOISINSMISONIONSIMINSIIMMONION.101001001 OVEN - 11111111s1MIhffl11111SWIIIIM1 . I i 110110,0115 I11001i .1116.6] POOL HEATER1.0011.0101.iiinglalli.110101111011aGrallgroliMit ROOM/SPACE HEATER 0.101.100.10.411.011.1111MMIlerniimil.M'Abainiali . ROOF TOP UNIT ; II I, _Iai , 1 �I i t IIIanal li l TEST010ltil1 �is�► Iili11 ,'' UNIT HEATER111.0011.118011,0.100101100.1.10.0111.11.1.0101.400.11a UNVENTED ROOM HEATER 11 imumM ishsllutlJ ' S i !i OT n11111t M lITI i1,i.111M111111111111 SMafinG11 1 1111SJISi.MIIIS 101 111115 1. T1111M11111 .10.011 1ff11fi111[SI;S111111111i111A1' 1ALG1111i IM ; 11116, _ 1M , li l l i f 1011IG G _ l7111MMG;AMIIAi�111111;IM_l#111870 1111111111g[MI�a[1mi-- J1111M1GN111 iM1111M1iA11tf1 ors INSURANCE COVERAGE I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL,Ch.142 YES LNOti I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY CJ— OTHER TYPE INDEMNITY D 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are Cr f,_ :nd ac •ratt to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In n e al), ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER•GASFITTER NAMEI . LICENSE# J}�' SIGNATURE MIK' MGF® JP© JGFr] LPGI❑ CORPORATION PARTNERSHIP©#[—�JLLC A•fir--J COMPANY NAME:LC l :_ ` /net'Pcp. i ADDRESS' 44 w" , r . ' ►• r " W,. x. CITY . .rs V ^, rw STATE mi./ IT I-- -1 FAX I,,,_•,,,•.,,,•,__,.J CELL 'EMAIL at Sb' e3citici Pc>mitc