HomeMy WebLinkAboutBLDG-19-002980 • ( so7- 'aq- 0s875-) • ..
a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY l I t/A,z,,a2li t DATE 11 / P /1 ? PERMIT#06-/7-0002
JOBSITE ADDRESS ) 91 13cn-y 4 ,n OWNERS NAME 73fc-r7 No/aer
G OWNER ADDRESS TEL FAXrr
PREEVOR OCCUPANCY TYPE COMMERCIAL 0 • EDUCATIONALUC ❑ RESIDENTIAL EY S b 'DO
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:p' PLANS SUBMITTED: YES❑ NO
APPLIANCES 2 FLOORS BSM 1 2 3 4 5 6 7 a 9 10 11 12 • 13 -
BOILER
BOOSTER •
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER • I
DRYER
FIREPLACE -
FRYOLATOR
FURNACE 477'C • I
GENERATOR
GRILLE
INFRARED HEATER •
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN •
•
POOL HEATER •
ROOM I SPACE HEATER RECEIVED 4.:
ROOF TOP UNIT
TEST
UNIT HEATER NOV 13 2018
UNVENTED ROOM HEATER •
WATER NEATERBUILDING DEPApirtk;wr
—_,
.•
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES arNO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ILS OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER: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 C
' SIGNATURE OF OWNER OR AGENT ' •
I 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 knowlec
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with_ all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • J/G/6��—
PLU,MMBEER=GASFITTER NAME alt
#11977 K SIGNATURE -
MP IJP MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION a s PARTNERSHIP 0# LLC 0# •
COMPANY NAME Capt, ad Flur>,6r.i( dill- • & ADDRESS f 0. uSes. 429 •
CITY S DGu,y/- STATE,t* ZIP n266o TEL Sot- .39F -zaz.
FAX CELL EMAIL Clitie9r4
(' P 50
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