HomeMy WebLinkAboutBLDG-15-005415 I`'lap i Parcel : . ..
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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r_ iirr-i CITY N\cc cresnkh MA DATE V-\\•L7,,\`') PERMIT#" bT ir-ed-577
ScSk JOBSITE ADDRESS \t mc' 0 . Q\CiUj ,- W.-CONER'S NAME 'Cf.�.Q-
Coll %.G. OWNER ADDRESS ..,*)---1 ,1ch N..CA''cCYJ(Tc'\ I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
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CLEARLY NEW RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NOD
APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8i 9 10 11 12 13 14
BOILER
BOOSTER ..,I_
CONVERSION BURNER I I _ I I t _I 1,_ I__.-J1
COOK STOVE
DIRECT VENT HEATER II [ 1I C ._.
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DRYER D I—I - - _
FIREP ,L_ [7 E
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MAKEUP a • .,'‘ Rs ,„ — - ' MONK
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POOL HEATER
ROOM I SPACE HEATER 111.11W.0111.0.11161.01,0101.1011.0*****KIIIIIiiik
ROOF TOP UNITri iMi .
TEST , ,
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UNIT HEATER
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UNVENTED ROOM HEATER 1 I r 9
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INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES rt NO ❑
IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY ❑ BOND ❑
lc 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 ❑ AGENT ❑
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 compile. - , ith all Pe.'•- t provi '.. . e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - - /'-- /�
PLUMBER•GASFITTER NAME O G r I 5 . p,I e d e 11 LICENSEIt Zrnr6 S ATURE
MP rgt MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION at PARTNERSHIP❑# LLC❑#
COMPANY NAME:Lc,rI Er. IR;rdell r Son IADDRESS 178 - Main Street i
CITY 05terv1lle I STATE I= ZIP oa6 55 TEL 50'&- H - Cc3Sn5
FAX CELL EMAIL '
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'20/729/
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