HomeMy WebLinkAboutG-14-088 0-u2035: r4 cis, flit st04 . .
ttlt, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
="kIo ;e CITY i/kn i Ek / ynp MA DATE 7 Ja/3 PERMIT# l�/�l-d 8g.
JOBSITE DDRESS d i/ nibet;nl 65-r OWNERS NAME ekr/.l•P ct""jp
GOWNER ADDRESS L • - TEL 6-0t 36a .2b be/FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES 7 FLOORS-. &4M 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _ r
r
BOOSTER i II
CONVERSION BURNER 4 _
COOK STOVE _
DIRECT VENT HEATER i (i _ .
DRYER � _ •- I �—
FIREPLACE r
FRYOLATOR f .r r I-- ;
1--
FURNACE r
GENERATOR
GRILLE / r
INFRARED HEATER -1. I
LABORATORY COCKS
MAKEUP AIR UNIT le r T
OVEN _
_ .. a _
POOL HEATER __
ROOMISPACEHEATER _
_< 6
ROOF TOP UNIT r. -
TEST
I ,
UNIT HEATER
UNVENTED ROOM HEATE- O , .�1�
WATER . : r
sT ����_- -- ��I
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sEP '''�% INSURANCE COVERAGE
I have a c' e .,r :t u ••Iicy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0
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I IF YOU CH ^6w ! SE INDICATE THE TYPE OF COVERA�G BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY OTHER TYPE INDEMNITY p 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 hue and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application Ml be In lance with all Pe ne9t provision of the
Massachusetts State Plumbing Cod Chapter 1422 of the Laws. f" ` pp--
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PLUMBERGASFITTERNAME `�S ,'3KR.J0s�J V0103LICENSE# �03 e" " SIGNATURE
MP❑ MGF❑ JP p JGF'_ LPGI❑ CORPORATION❑# PARTNERSHIP 0# LW❑#
COMPANY NAME:La '
� QJLJc,., ADDRESS /y) /4)c'es ciQ
CITY (V';S404J �reVA JSTATE MI ZIP ag f/P TEL 7 7 s-ty6 -7‘s-a._
FAX CELL // EMAIL
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