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HomeMy WebLinkAboutG-14-194 _ i7o .. w - .., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I .f CITY Ll. r[ . rr r MA DATELa/ /ft,) PERMIT# H1/4 M JOBSITE ADDRESS-&„1_11.1,7Q r Qty I OWNER'S NAE 1 4.5,_Igo • / GOWNER ADDRESS TEL • 17a• /pJS7AX j TYPE OR OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION:© REPLACEMENT:❑ PLANS SUBMITTED: YES D NOX APPLIANCES 1 FLOORS-, BSM 1 4 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ; I \ 1.... `•m. � dtl u ••-••MM k{ILIW nl'3 !..!'1 'r 4,„, V`fl 1 AA4 AIY' '6:;.beY' a\A wL BOOSTER 11 i „; 11 I CONVERSION BURNER r: — COOK STOVE r i DIRECT VENT HEATER i 11 III Il 1 i i' it DRYER -.' d, 1 i u e I FIREPLACE FRYOLATOR 1 1 1 l FURNACE ( lt i-` .. .. � � � � . • ., .�-.. ti . i GENERATOR I . GRILLE ...11 _ ..: b _. 'i. le«•ti _- a.l::. r a_'- , INFRARED HEATER II ,i - I 1 I--.._i I LABORATORY COCKS •• MAKEUP AIR UNIT POOL HEATER 1 1 ROOM t SPACE HEATER ROOF TOP UNIT IS tartilail A ER 11 14: 7 + 0. I� � OT;-• 01� y $cOINIUMIII P D3 •�-�. f�I ILS aril ` U �"�_�, • INSURANCE COVERAGE I lability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑NO Z I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Cp OTHER TYPE INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the i. • • setts General Laws,s,and th y signature n this permit application waives this requirement. / "2/ CHECK ONE ONLY: OWNER GS AGENT Ej SIGNATURE OF WNER 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 ,a best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in campl':nce with all -a enc .visio of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 3..f 4!-, .(�(, '. 1LICENSE#InnS7 I v SIGNATURE MPX MGF Li JP Q JGF J LPG'L CORPORATION®#_, J PARTNEERSHIIPP0# LLC LJ# CITYCOMP (NI►1 f1NAME:D GENE— Gf�y J ADDRESS + STATE Mj4� itLGU PA- J EL' ""A lfR71.4-1?- 16D FAX --_----I CELL !EMAIL c �lzz-1zoo — i1e._" 0k • • • • ri _