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BLDG-15-001730 _. . ). MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -• _ - — it gin y � MA DATE; //f :PERMIT JOBSfTE ADDRESS; 53. E O ¢ OWNER'S NAME LinED LF OWNER ADDRESS :. " /I u 1TELaf-3z city Taxi __-- j TYPE ORCOMMERCIAL j EDUCATIONALTi RESIDENTIAP6 — - PRINT OCCUPANCY TYPE - _j NOL_:NEW. RENOVATION:;..i REPLACEMENTS PLANS SUBMITTED_ YES i4 5 6 7 8 9 10 11 12 13 f 1 APPLIANCES FLOORS Bsyt 1 © 3 ISOMWel MI at - ' BOILER MI UPI S S� I BOOSTER 111.11101 MSS etillillill IMS11111 war 01111 i CONVERSION BURNER insis COOK STOVE 111111MAIIIIIIINI SKS_OM WO nallatailling Mt . I DIRECT VENT HEATER NS S . DRYER - FIREPLACE S S' Lff 0 III 111111111110.SS Ma_ FURNACE MO II ill —IOW SU I FURGENERATOR T ; 1S- 1OPE isik _ _ 1s _ INFRARED HEATER COC SSW*Jai itaill MIS ma LABORATORY COCKS MAKEUP AIR UNIT rsaS*t OVENillik OOi Simitair is S S _. POOL HEATER - � _ 5 - ROOFTOP UN HEATER $01/11NSW -. ROOF TOP UNIT atintaili anew MO WS _ t fr TESTSigigins_ I UNIT HEATER i _ ___ _ UNVEN r s ROOM4IEA • = WA . HEATER c, - `- - IOW ' OTHER: :i o Or sr ---- iliNagatatanaginalann I r---Nz- INSURANCECOVERAGE .__...LTC'tC9 Et-frit-Brit:, I By or its sup�ntiai equtirWad W i:cti meets the requirements of MGL Ch.142 YES NO I I have a rare � insurance�� CHECKING ifrE AppRpPRNTE BOX BELOW ' I IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGEn UABIUTY INSURANCE pOLICI(�i OTHER TYPE INDEMNITY fl BOND L-: OWNER'S INSURANCE WAIVER I am aware that the licensee does tut have the insurance coverage required by Chapter 142 of the that my signature on this permit app�OD waives this requirement Massachusetts General Lawsyard •.. I CHECK ONE ONLY_. OWNER s AGENT.- _- I ------116W-NA OWNER OR AGENT ties application are true and aoatrate a the best of my tv,anAe I hereby certify thatadof the details and' perform 1 nave r per erertmed regarding�d for w�be Si marc - rxwision d the, and that al plumbing work and ista7ations performed under the permit - Massachusetts Sate Mulching Cade and Chapter 142 of the General Laws - L. ,z 4-- - T USES:// -7t SIGNATURE PLunneEa GASFIrrER NAME A I -- G' €, `��"`f' ----, I Tl0N y. �PARTNERSHIPi.::I i LLC,'MI I tdPX MGF_.: JP:� JGF'— LPG''i_ CORPORA � �� y nErFl� 'AODREss rt3 I- 1i' in / vF____ _ _ COMPANY NAME:�pF,_;ri- 4) abro - - ; STATES, tZIPCW A lTEL% C-( (-'i S4I fes - : i I FAX {'i _ CELL1EMA1L- - ' v,..�A - : zs . . i I _ _ _ .�r. — tneri r i 1 . I I I I I I .-- . 1 I I I ! I I a..i I , 1 I 3 1 I . I I I . I I I I I I I 1 1 1 I 1 . 1 1 1 I e i I Pl.I 4 :-7 40;1 . : I . . 1 . I I I a • I 1 J. i I ! ! •. S •• —0 m 0- II1 Xi I I at I 1 ' I I I I II •. 4 4444 1 i I I . Iii Oil Sr I ill I I I I I I - _ I 11 I I I I i I i I I I I I 1 1 1 I I 1 Ii • I I I I ' " I I I I I I 4 I 1 I I to i I i I - I I I I I I :_ a. I .