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HomeMy WebLinkAboutBLDG-15-001259 wyRO /hay MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ld lci (M (1 J MA DATE v� PERMIT#,1X-06-/S--/a f • JDBSITEADDRESS �� , do vJs ✓l c JOWPU'S NIWE I f J Y: C1li l l✓._____._ i G OWNER ADDRESS L w _tint TYPE OR OCCUPANCY TYPE COMMERCUILD ®UCATIDNN.D RESIDB111N PRINT CLEARLY NEW:Ef- RENOVATIOPt0 REPLACBENT:0 PLANS smarm): YES El NO( .K. 1 FLOORS-. BSM 1 2 3 4 5 8 7 8 9 10 11 12 13 14 BOILER BOOSTER COOK STOVE { lisinanbulis111111111111111111111MINNIMININNIINININININIMINNINEININIENNININININ DRYER MININEINNIMENNEMENNINEMIEINIENNINIENNININEN FIREPLACE IIIIIIII♦NMI NINES NEINNEININ FRYOLATOR 11111111111111111 INN FURNACE INININENNIN GENERATOR 11.111.11 1.111.1W MS= '_ IMIN GRILLE INFRARED HEATER -uhII � LABORATORYCOCKS IIIIIwIEn IINININIIIEIi r IEININ ' MAIEUPAIR UNIT INIMMENINI NENNEEININE NIS ENINIKEINENINEINE OVEN 11011111.1e11011111111.1111111111M110111111.111111111111111111111111__ POOL HEATER III IIIIfI ®ENNEMEINEIENEMI ROOFTOP UNIT E1111I11111®IIIIIiEIIININ(ENNUI#IEIIIIINEUIIIIi®IIIIiI TESTIII NEN ENIII_I_IIII __ I I III�I_III_ UNIT HEATER IIIE�E�®� � �____� NINNISI®NE WEINEMINIMINIENNEMEMINEMMINEININ WATER HEA : � —� ��� �� DTH:- INIIIIINE®NEI_LII•IIENNI —MINIIII1IIII III•EIII! F .�. EMI WHIMS E111 NEI IIIA ®E� INSURANCE COVERAGE . Ihave acurrent Kabl9LvSac!policy or Itssa epdvalentwhich meets the requirements ofMa.Ch.142 YES NO C I F YOU CHECKS)YES,PLEASE WOICATE TIE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABUJTY VISURANCE POLICY omut TYPE BL ma n D BOND 0 OWNER'S INSURANCE WAIVEIt:I am no 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 Egm this requirement CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGER . I hereby ceNryBhat al dthe details and Mmnation l have wdrW[ed cc entered regarding this apperalb_are true :•• .:n:to ... ._. . ray lunwiedgo and that atlpNaS plumbing t and =perfumedudertheplssuedforthsappficai tiallbeln�-•':'�.; �. • rite Massadasalbm StatePibitg-CodeaiCapea142dttteGeneral Lea ��j /� PLUMBER-GASFTITERNAME .Iif l/ <ac/ 1��sE# TWO SIGNATURE • MP E MGF D JP JGFD LPG D CORPORATION©# . ., J PARTt HIPp#t._.,. .,. }LLC L;'#I._.. COMPANY NAMEL:1111AP$ l ADDRESS t T CITY Ithb_. 1PSTATE Iy (>Z. LrL[ 2 ,,NITBL 5a/F=7,: p._. e./A. ._ . _ FAX BJAILI �t! Q/17�y