HomeMy WebLinkAboutBLDG-15-002880 / /
N,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK •
v
n
an'Ly .,.a., MA DATEL 1 t 4 PERMIT# /,-46*-/r Wong)
JOBSITEADDRESSI ,- __F.I y4410.14 •IOWIBSNAME I. 4ILSP__JZV
j
G OWNER ADDRESS "NAY AFAXL —E--7---
-
.. ._ .
�OR OCCUPANCY TYPE COMMERCWD EDUCATIONAL 01 RESIDENTIAL „Pr
c usur.-'
NEW:Et RENOVATKkL•0 REPLACI3AENi 0 PLANS SUBMITTED: YES 7,-.1_ NO q
APPLIANCES 1 FLOORS-' 891 1 2 3 4 5 8 7 . 8 9 10 11 12 13 1
BOILERp�� p � r _ _ .
CONVERSION BURNED •-"•'.. e ._C..J ... _. _...J_ .1__, _l A .Vr 1 . -. -.. ..4W._ ., -...
COOK 1
COOK STOVE •
DIRECT VENT HEATER _ a _: _
DRYER
C: L w/ v " F 1 R-
FIREPLACE _ .3
FRYOLATOR C p/C��} �-.. / _ _
FURNACE c,"fiv 1 i 9 It, ,�� w
GENERATOR - ,
GRILLE ..
INFRARED HEATER; u' - 67 L
LABORATORY COCKS
MAKEUP AIR INR ,
OVEN •
POOL HEATER
ROOM/SPACE HEATER - .
ROOF TOP UNIT
TEST ,
UNIT HEATER
UNVENTED ROOM HEATER
WATER EATER •
OTHER - ft P m I
INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES !NO D
IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECIQNG TIE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ; OTHER TYPENDEWATY 0 BOND IT. -. ,
OWNER'S INSURANCE WANER:lam aware that the licensee does not have the Insurance coverage required by tempter 142 of the
Massachusetts General Laws,and that my signature on this permit application sag this requirement.
CHECK ONE ONLY OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certifying all d the details and Into meaan I have summated wagered regarding Ns applies:ion are ' : to . .,_, S �;.• ,
and that all pkmhkgwork and kef�atiampedarmedoderthe prima fairedfor this application vet bein ••�. * .,_Als -+ • - ^ are
Massadacelb State Plumbing Code and Chapter 142 dare General laws. ..411r:5 rildeetre., ..
PLUMBER-CASA-MR NAMEICil05ft)//7L✓ 11 cn atti_ uce4sES[107a S
Et GNA
MP� MGF� JP D JGF D LPG!I-1 CORPORATIONE l J PARTNERSHIPEt j U•C CJI.. ,
COMPANY NAME'.L4.Yrettis P 'ADDRESS Lt 3$ __,„ _.._...s_
carr L..int Iac_kia_is ter.-- . _ 1 sTATE tt. ZIP1 62-14die,,. JTalA24 77s-9/IL—)
FAX! ... . IC3 . �, . .., IEMNL . . _ . . . -_.
1i
IL