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HomeMy WebLinkAboutG-13-1037 t.�, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ' .rit17•_-I$ CITY 1-7-p,—,rier,rs th ` J MA DATESVC43 ---J PERMIT to 6/9—/09 / JOBSITE ADDRESS % Qt$ a s rya q_N. ICI A OWNER'S NAME (�']__ �Oghh Q `f G \l � CP�F�y� OWNER ADDRESS SgpNIL TEI,f S0$• 3°1`i rt TYPE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIALLY CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES Li Noy, APPLIANCES 1 FLOORS- BSN J t J 2 J 3 J 4 J 5 J 5 J 7 J B J e J 10 J 11 12 J 13 J fl BOILER BOOSTER • CONVERSION BURNER , COOK STOVE �" DIRECT VENT HEATER DRYER -41• r • . FIREPLACE , FRYOIATOR4 FURNACEIt -e- IMP' r , GENERATOR GRILLE • r • INFRARED HEATER r • ' , 1 LABORATORYCOCKS MAKEUP AIR UNIT t OVEN h r p • r , a. 4 1 4 POOL HEATER • r ROOM/SPACE HEATER ROOF TOP UNIT r TEST r 14 4 r UNIT HEATER , s , UNVENTED ROOM HEATER • WATER HEATER 1 _ 1Tff1III_J R INSURANCE COVERAGE I have a currant Iiabltrt insurance peaty or Its substantial equivalent which insets the ragtrtrsn.nts of MOL.Ch 142 YES NJ NO LI I IF YOU DECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE W OEOON G TIE APPRDPRMTE BOX BELOW UABILlTY INSURANCE POLICY ® OTHER TYPE IIOEMlITY (D BOND ❑ OWNER'S INSURANCE WAIVER:I am arse that the titan..•shat sin the Mance eovwape required by Chapter 142 of the ihasschusalta General Laws,and that my*mature on this permit application us this ragtthmant - CHECK ONE ONLY: OWNER ❑ AGENT I SIGNATURE OF OWNER OR AGENT I hereby certify that al d the details and Minton I In ettin�B.d or embed reprdng to.p talon ata hue and Si,hest d my Iun+wdge an that War as putty p and trt.taeatlora pe'tom ad win the peas Aust for eve.aaauot awill ben campus" Forme a Or Mweed iaetta State Plumbing Cade and Charter 142 of On General La , 1 e PLUMBER-GASFITTERNAME FcerS2rtck '(00Xyngrh JLICENSE Ir %6l SIGNATURE MP'Al MGF Uj JP[J JGF 0 LPG(0 CORPORATION©a r2 ssPARTNERSHIP EJ - - - H LLC(_]N4--_-.._ COMPANYmai Cctn Qlyr'r\can5S¢r�Kos\INcJADDRESS \ \r�a\\\ncjtorb d CITY ':t_vnco\f j STATE ca. ZIP c %156C TEL LjoR 63c'1 `i`6yA FAX 1 CELL 4wCs•1`Civil EMAIL p I . Z/ i ULF 71a *fe UU LsCPT ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES • Yes No THIS APPLICATiON SERVES AS THE PERMIT 0 0 I • FEE: $ PERMITS . ?LAN REVIEW NCY17, I I I -• • • • • • •