HomeMy WebLinkAboutG-14-926 50 - ats,c), ?o#- IQ-`fCoq 1-7 L_____
'1' • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING
a _ 7___WORK
af
CITY (/ (�--
j MA DATE LL PERMIT ,•,'71''
'•' JOBSITE ADORESS f 3qh n a+F AJt1 I OWNER'S S f F leG 7
OWNERADDRESS I ITE _r
•
TAPE OR OCCUPANCY TYPE CCMMFRCIAL❑ EDUCATIONAL
CLEARLY ❑ RESIDENTIAL,
NEW:L] RENOVATION:❑ REPLACEAENT:[ • PLANS SUBMITTED: YES D
Nod ;
APPLIANCES 1 FLOORS-. BSM 1 2 1 3 1 4 5 1 6 I 7- L 6 9 J 10 j 11 12 : 13j14 '
BOILER
BOOSTER • •.• . . 1
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER i
FIREPLACE rw.,
FRYOLATOR �
FURNACE ` 4�
GENERATOR •
i•••••••GRILLEi•••••••
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
r
tV r
OVEN
POOL HEATER •• • ': a„.,e,�,�„
ROOM/SPACE HEATER ' '
'
ROOFTOP UNIT
TEST t -a v :� .... ` d....
UNIT HEATER r r }
UNVENTED ROOM HEATED
rtoA /1114
BUILDING TMENT INSURANCE COVERAGE 1«��
I haw a mar«$j tFoiicy a its tubearltist**ivied altidt ma is the regtir.rmnts of MGL CIL 142 YES
LTJ NO �;
I F IOUCliEO(ED YES,PLEASE INMATE TI-E TYPE OF COVERAGE BY CHECIUNG THE AAPRDfRfATE BOX BELOW
i •
LIABILITY INSURANCEPOUCY ® OTHER TYPE INDEMNITY 0 sow Li
OWNERS INSURANCE WAIVER:I sm mars that the Bane*Ow not here the Insurance cowry*reqund by Chapter 142 cf the
Massachusetts Goners]Lars,and that my sigratba on this permit scOcation yea,'this requiems-it
' SIGNATURE OF OWNER Cf2 AGENT CHECK ONE ONLY: OWNER LJ AGENT
I hereby cerdry has at at the details and Momaaon I haw stbrnit ed or erwred Waning tis.rcacaann re eve and to Mn beet of
and that aa Its S rartc k Codehataaand
soarpreformedunder C Coropre-nzal
L.i aea.x dee applies don r.+l be n conoYert.�
Massachusetts Suite P4mtirrp Code W Ctnger 142 d the Cm+eral Lana, � Of9AO�u provision or the
PLUMBER.GASFITTERNAMEICr¢.tCrr cis �otc'l�m I LICENSE#�ZOJ SIGNATURE
MIP_x; MGFL_J JP I`] JGF❑ LPGI0 CORPORATION[]i[ Zc;c PARTNERSHIP I
COAIPA)N LLUE;`GE`'1 Qlym',0 S2colcQs\n ADDRESS \ -
5 � . _r wc�\,n5-ion
1 CITY a\r1" \r, I STATE(F�-z-1ZIP 1-OZ.cSUCIJTEL I�1o1 63`1 " ----:..:
FAS— ICELLI4QLC3`i`LoYIIEMAIL' ----- .---.--..__...
r
;
•
•
•
•
•
•
•
• tB,LON mawatl Ntl'IS
I11WUI3d 3 333
0 ❑ !Mad 3H1 SY S3AIi3S NOLLVO 1ddV SIH1
• oN BOA
SAXON NOUY7 SSN1'IWNLI X7NO aSII 1101.oraSN1110,139dd SID•L SIA.LON NOI.LLJ JSNI NV91tL)fIO}I