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Home My WebLink AboutBLDG-15-002960 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `._ CITY g. 6I eilla Gd k-- - — -3-MA DATE WAVY-YPERMIT# Abe-15-to Oh 0 JOBSITE ADDRESS Vile f1n/�E2 Q ( OWNER'S NAME I A/E .0.--A/"- MJ GOWNER ADDRESS ^ J/ / f n f TELES-0-& -/.2 y0 'FAX i --- TYPE OR OCCUPANCY TYPE COMMERCIAL.--1 EDUCATIONAL Ti RESIDENTIAL/CI PRINT CLEARLY New:_ RENOVATION:0 REPLACEMENT:-rj.�-'+ PLANS SUBMITTED: YES°_,; NO_. t APPUANCES 1 FLOORS-. 1391 1 2 3 4 s 6 7 8 9 10 11 12 13 14 • BOILER — .Nil-11111MIMISISMINBai gam . - BOOSTER I.OWSSI-ISS j CONVERSION BURNER IIISSIIIS a SwF allaillinlill S.: : l COOK STOVE elinlinatleallitlaiMiellingearlinallie . I DIRECT VENT HEATER NMI NWnI MgIS51— I ' S DRYER ssintogysigw.aSu S IONSOIS FIREPLACE as ma osisitestos0SO FRYOLATOR tinSiollimmt 010111110111111.111111011111.1 i FURNACE n _ GENERATOR ilia 111111111.MIS ilitS GRILLEa S _ INFRARED HEATER ien.aW LABORATORY COCKS 0. I MAKEUP AIR UNIT S n - anse OVENS MS SSW SiiitilitilliSMIIMIK POOL HEATER lie IS- - StSWOS MOSIIIIIIIIIIIIINS- ROOM!SPACE HEATER _ gillialialli Salt.MI SW SSS I ROOF TOP UNIT WI .. . . TEST MI IS OM_ -- Sal s - UNIT HEATER SiSiMrs t WA R HEATS `" '' _ EM M WRIM 0TH R: C{C .S9._ : _s imp— . S aillil _ tillitsit at _= trS_ . Buiti r,—b/tN — INSURANCE COVERAGE - I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES, NO I F YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW '' ,, LIABILITY INSURANCE POLICY 114 OTHER TYPE INDEMNITY j BOND Li OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Lawsrand that my signature on this permit appbcation waives this requirement CHECK ONE ONLY:. OWNER 1•AGENT SIGNATURE OF OWNER OR AGENT this are true and accurate to the best of my IcrovAed I hereby certify mat an of the details and information I haver the Oed a entered regarding a p app6catim and that al plumbing work and installations performed under the tin issued for lit ADD will be Si compliance hwit ertinaN provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _� �1.f ` . s t i PLUMBER-GASFITTER NAME::-Nt R 1 'L. 36A/ .�,,{J LICENSE#•« s"(+ GG SIGNATURE MPX MGF :2 JP JGF LPG':i CORRPORATION} # 7Ie I PARTNERSHIP #j.— j LLC-1/$:— COMPANY�NNAjME: Sr() n't&'E-f t�F.� T ADDRE`SSI a-3 Lava, 4 L'CL.____ __.�-- CITY Ph9-//11ii is ----- —I --Ira WWI jEMAILc -t 9 i2 . 1.'A - i let: s A/er—__ FAXS�ir�S�c}:CELL':_ -- - �'%'� ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES ----•— Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ -------. .._...---•----__._.---. .._._____ FEE: $..._......._.-_--_._. PERMIT H _— PLAN REVIEW NOTES