HomeMy WebLinkAboutG-13-928 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
•
CITY S 144.1.4 774)47-7.4 MA DATE 91/1/l '3 PERMIT# Q13-- tze
JOBSITE ADDRESS I L / Jet✓- -, 57 OWNER'S NAME /647-c Cc& ✓�
G OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL I�
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: Er PLANS SUBMITTED: YES 0 NO
APPLIANCES 7 FLOORS-' BSM 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 •
FURNACE
GENERATOR
GRILLE �
INFRARED HEATER i0//
LABORATORY COCKS [,
MAKEUP AIR UNIT �n
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
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 Et%' 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ly— 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 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 true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In compliance with all inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME '3 /41/ ,44 L�6cp Lf LICENSE# 11177 SIGNATURE
MP IIKMGF❑ JP 0 JGF❑ LPG!0 CORPORATION Sr- PARTNERSHIP 0# LLC❑#
COMPANY NAME (Melt. Co ci VAN /%' L ADDRESS /0' 0 ' ' -SDK 9 L 9
CITY 5' -0 est/A/I 1 STATE /779 ZIP OZ-6 6 o kg15,
IJj
FAX 516A-3V —ttc P CELL EMAIL APR 1 1 2013 u.
4 y4 i 4vo .