HomeMy WebLinkAboutG-12-698 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK'"
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c;,lj�, CfrY I Yrt v7 yr o_kJ.1-51"1 MA DATE 5-r7- la, PERMIT#C 12,69 11
JOBSITE ADDRESS t'5'l tig,ti Um p DA ., OWNER'S NAME I fri.e lv5 0 b b cO j
G OWNER ADDRESS SCvrilR _ TEQ5Og-`10+ -X55119FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[
PRINT �.,/
CLEARLY NEW:L tY RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES NO[11
APPLIANCES 7 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER i I ;; f P r
BOOSTER 11- r I, 1
CONVERSION BURNER 1 1 I'` I' �� Ii it ,! i . it li
COOK STOVE 1 ,_ 1 ,
DIRECT VENT HEATER I ((
, ,
DRYER ,4 1
FIREPLACE l
FRYOLATOR 111410
11111 ill. i
FURNACE 11 i
GENERATOR •
{ill; l I , I
GRILLE
INFRARED HEATER 'I
LABORATORY COCKS
I int i r
MAKEUP AIR UNITIT it i
OVEN
POOL HEATER li 1Imiogionsen : i
ROOM 1 SPACE HEATER ii i.
ROOF TOP UNIT _;
TESTRN 1
UNIT HEATER 111
UNVENTEDHEAT ROOM HEATER ��' illl � �
WATER HEATER G et _ , : �1 _, _
OTHER R` G ` Thy IThri 'IT—,'m �as ion� 1 i In
1. 1 l 1 r j; 1
tL. n CEP t INSURANCE COVERAGE
have a current Jiability •su at&e •• • its substantial equivalent which meets the requirements of MGL Ch.142 YES ENO ❑
IF YOU CHECKED YES,P a• ev NDICATE THE TYPE OF COVERAGE�,/ BY CHECKING THE APPROPRIATE BOX BELOW
1 LIABILITY INSURANCE POLICY LB 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
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CHECK ONE ONLY: OWNER 0 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 'Ali; accurate to e bes --•ge
(and that all plumbing work and installations performed under the permit Issued for this application win be In .. with all the . of.•
Massadwsetts State Plumbing Code and Chapter 142 of the General Laws. •
PLUMBER-GASFITTER NAME XcV/N. /)] r(„eingWE LICENSE# /2Y6 SI •
MP[34 MGF 0 JP❑ JGF 0 LPG!0 CORPORATION Ilf# a 5s5J PARTNERSHIPDI/ LW❑#
COMPANY NAME:I y nn- (Iv&nv/.e5 d bye., ADDRESS /6 Y .60w 4i7nn r
CRY ri
y belj0RO . . _ STATE ",9- ZIP a'43,5 TE Od- 3 u!/Y
FAX g4 -'9/z ]CELL[f& d 05.7 EMAIL 5!7 .crO
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