HomeMy WebLinkAboutG-13-545 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY /Ghat . I MA DATE /PJv//a (PERMIT# b/3 - S
ASO' JOBSITE ADDRESS 3/ flint S#. S )/cvnxu� IOWNER'S NAME 1Z/9144s/9-UeR
G OWNER ADDRESS / I TEL 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL$
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO�,
APPLIANCES 7 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER �� . II 1 - n(—t—I -
jt CONVERSION BURNER
COOK STOVE J J 'I I
a' DIRECT VENT HEATER Ir- I !� I! I 1-11-1-1
DRYER
FIREPLACE
FRYOLATOR ! ii w,. !' crr�!
FURNACE tlayr�1 I(—Thrlel .' -f(y I I 6 II
GENERATOR • •
_. !C , _,: .., ... _ ! .._ . �_ ,+ ._.. C _W. ,_. �. '!
GRILLEIII. tt 1 fl 1� ,_I
INFRARED HEATER I1... J I r"-,_„:111-t-", i,
LABORATORY COCKS I�
MAKEUP AIR UNIT Imo , � ! !( ISE —I FY-MEM:- I
OVEN I f IP I F"--77.•
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POOL HEATER L.S_ -!(SII f fid _
ROOM/SPACE HEATER _ ILa,
-_ I �.. I ;I f I f -!
ROOF TOP UNIT I .., 11 .,, 8�1( 1I77r 1 _. I I 1,,_
TEST 1
UNIT HEATER ._. I dr-c—r `!
UNVENTED ROOM HEATER '! 1 I I,. ._ I I i I ��I 1 „,,.I
WATERHE-TE. I S t', I - 1 . , ,I
OTHER �I ._ I 1 _
. MIIMMES
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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 ®NO D
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY lj OTHER TYPE INDEMNITY ❑ BOND
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
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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Ant
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PLUMBER-GASFITTER NAME LICENSE#1-firi#1—firSIGNATURE
MP CI MGF❑ JP❑ JGF❑ LPG'ID CORPORATION Q# 174 -C PARTNERSHIP 0# LLC❑#
COMPANY NAME: Rurn'/s Tnc. I ADDRESS A2-a Mrd-Teck pries
CITY W. y0✓nia1,7lt I STATE MA ZIP 02473 T So•- - I
FAX 508-771-9310 CELL EMAIL L C [ I .,1� 1
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