HomeMy WebLinkAboutBLDG-15-002450 ‘ ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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ill- CITY Yebt n0/AI , ' MA DATE AO.30, /c/ PERMIT#ft r 510.2 S6
ti JOBSITE ADDRESS 3,17. /'l,q g kAis Cora U.e_I I: OWNER'S NAME H'H4 j I pry t,q„j( .
GOWNER ADDRESS Sain_at J _ ? TEU.Ot- ;J)oAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL[
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES NO❑
APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 11111--- dl- 1
BOOSTER ;I —( —v- f -7
CONVERSION BURNER Ir.— II i i IE iI +I
COOK STOVE + I :I - .I m
DIRECT VENT HEATER I ll ( 4 v 1' _r ( i 1 _ I
DRYER n-411 d i 7 7 n
FIREPLACE a gI I I
FRYOLATOR r
FURNACE 11 11 I II— ;r-_ _1 I( ,II
GENERATOR i 11 I ,I
GRILLE I -I - II — I II ,
INFRARED
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_ I_ r If
LABORATORY COCKS II li 1 �'' , J ,1 I
MAKEUP AIR UNIT 1
ROOM/SPACE HEATER I 9 I -I
9
POOL HEATER I ---1 4- f I
ROOF TOP UNIT allilinflal -- '
TEST An
UNIT HEATER .,.�___.__� , I- 7 I
UNI/ENTED ROOM HEATER= . I -i' 7 � -�
W.TE- HESE uc
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fi(i r f Il)7i I �'I [-� _ S �(—
BY _ Pie INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ❑NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance all Pminent provisioneof the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �jt��tJ t
PLUMMBB(ER-GASFITFERNAME Krb4v,3her nekIt{1er LICENSE# /572;7 SIGNATURE
MP L� MGF❑ JP❑ JGF❑ LPG(❑ ' CORPORATION(ott 3 z0 7 PARTNERSHIP❑#n LLC❑#
COMPANY NAME: MLA i ADDRESS j Pt/ &€ J?U
CITY L' ,sl f,ti- STATE ry1R ZIP 62,4f/ TEL ?5< 3636
FAX CELL EMAIL
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