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HomeMy WebLinkAboutBLDG-15-001196 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `_ f </A2I11U(>1"I11 iw DATE H PERMIT,11 obis-colic • • JOBSITEADDRESSI sg Eid t rir e SF. (0WNEWSNAMEI�2 eus5 J) I • • G OWNER ADDRESS i • ' * . (ml • • (FAR • • PRIN • TYPE T •OCCUPANCYTYPE . COWAERCIAL❑ • •EDUCATIONAL0 • RESIDEMwL0 ' CLEARLY NEW:0 RENOVATKON:O ..REPLACEMENT:l ANS •. PLSUBMITTFk YES NOD • • APPLIANCES 7 FIDORS-' assi 1 I 2 3 4 I 5 6 7 9 1 9 10 11 J12 13 I 14 BOILER I A . Li CONVERSION BURNER /a� - �; COOK STOVE.' ! �� - - - - DIRE VENT HEATER • _ . DRYER•. FIREPLACE ' . • FRYOLATOR _ FURNACE • - • GENERATOR GRILLE • : INFRARED HEATER - LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL'HEATER tikan is; mrlisjs ailaingst ROOM/SPACE HEATER assemine, ROOF TOP UNIT 't UNIT HEATER INVENTED ROOM HEATER a _ WATER •EA in: ._ , gig a _iiaia ER MSAME. narnat WO MN NSI . INSURANCE COVERAGEI I Ihave acurrent liabiTdra vitsancepo&ry or BssA�ntialequivalauwhich memthe tMGL. I.of42 SEYFslthNOS�I IFYOU CI OKDYES,MOMINDICATEit9:T1'PEOFBYCt' GTHEAPPROPRIATEBOXBELOW -EtIIILDI TJ LI GDF RAYINSURANCEPOLICYCLwIOTHER TYPE . r = OWNERSINSURANCE WAIVEIE I am aware that the licensee does-not have the insurance coverage required by Chapter 142 of the._ Ciaefad Massachusetts General Laws,and that my signature on this permit application nbces this requkemert. • CHECK ONE ONLY:-OWNER 0 AGENT 0 - SIGNATURE OF OWNER OR AGENT I hereby catBY tad:et olds detab ad hiatmianon I tuns submitted or entered regarding tds appicatbn are Ins and ornate b the bed of my knoSedpe end that all plumbing wdcand hdalla9vis brimmed under t the nonaligned far lids eppaca9rn w be In complia ce w al pwWm a9ro Mamachuseds Slab Fluting Code end Chapter 142 orbs General Jan /�r • PLUMBER-GASFITTERNAME 1 K2v:•. Mcgr:Cie__ ILICENSE#® SIGNATURE . up El LIGE 0 JP 0 JGE,0LPGI© CORPORATION Eft . .6R G PARTSFIP NER04 KW 0' • ' • CDMPANYNAME4k 04,(*Br:tie Mem 4-LI tc.:1 1;4 ADDRESS I II rac.11 escri IIC..4 1 'CITY 1 W elemrrug 1 STATE FM ZiPI 42673 ITELI CSo&)-7-78-4656 - 1 ,, FAX) I cad • IL]AAQJ ( 1