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HomeMy WebLinkAboutBLDG-19-003144 70 , to FSR J..• , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK li= CI7Y , IAl Linin' l\ DATE, /1/J3//6 1PERMIT#f,4o %q-a 6Omy7 g JOBSITEADDRESS mmirA a1fl Moi /7(E,• , .S NAME 1 C.p 1ecc ✓, - I G OWNER ADDRESS - L 1101 1,59 774/FAX • , TYPE OR PRINT OCCUPANCY TYPE COMMERCIALD EDUCATIONAL RESIDENTIAL CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[a PLANS SUBMITTED: YES© NO El APPLIANCES 1 FLOORS-I, ESM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER aa�� BOOSTER Q, _ —. COOK STOCONVERSVE BURNER �+ -11 C DIRECT VENT HEATER it 1I I - tl DRYER $ ,.,Arte .. _.� as f ! FIREPLACE �. _ FRYOLATOR • t .'-r— -ir I— - _ [ . — i f-�' FURNACE ' „ ice . -1 . . GENERATOR GRILLE . . ( _ �, ILL INFRARED HEATER r I " I I '' -- �i LABORATORY COCKS t —A ' _ '- --; ' MAKEUP AIR UNIT OVENS Imo!—�! A- r ROOM I SPACE HEATER ROOF TOP UNIT r _ TEST 3 I �I UNIT HEATER AI' i! _ * . UNVENTED ROOM HEATER - j t� ! .•t vuo a1I M ,: WATER HEATER OTHER I __.._ ___!I - - * ailiSEt - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 9 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 © AGENT 0 SIGNATURE OF OWNER OR AGENT 1 hereby codify 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i C42) 0n--� PLUMBER-GASFITTER NAME Craig Bishop IUCENSE#J15101 SIGNATURE MPS'.I MGF© JP 0 JGF 0 LPGI0 CORPORATION 0# I PARTNERSHIP 9#MINIMIN LLC 04 111.1111. {{ COMPANY NAMEHigh Efficiency ADDRESS 378 route 130 t CITY !Sandwich I STATE' Ma IZIP 02563 ITEL1 I FAX ' CELL EMAIL admin@high-efficiencyllc.com I Z.12y $ 11) G� a-t 201-zy/ 7v "--7 ) o 4