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HomeMy WebLinkAboutBLDG-15-002131 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1. CRY ITown ofLe YrYzrvtA ( MA DATE)'0olf_4— SPERMIT# 1JZ'OU-/SOo,T/3/ ��``11 JOBSiTEADDRESSI Ito talw)t�g�"'C (OWAM NER'S NE) SF1A..,.) GOWNERADDRESS ) tcva--36�wv7 (TEE (FAX) • I • T YP$OR OCCUPANCY TYPE COMMERREIAL� EDUCATIONAL 9 . RESIDENTIAL PRINT CrEEARLY NEW:D RENOVATION:0 REPLACEMENT:© PLANS SUBMHIal: YES© NO 1:1 APPLIANCES I FLOORS-+ BSM 1 2 3 4 5 ti 7 ' II 9 10 11 12 13 14 BOILER aS�5.a5.111....1.11.1.11. 1.1.1.1.11.1 Nita BOOOS I EH NVERSION BURNER 1�f S S illy ' -_-f COOK STOVE —iMILIS -- . Uig - iiiii DIRECT VENT HEATER IllInra>lilllTt)rlaS>titi itMIri DRYER 51S•_s—raE5 $ —IM SAM�a of W 1>e milin FIREPLACE FRYOLATOR . { I- r_ � '�e FURNACE-.. • --5 �.flWflS!iful' ST —IIMC1 GENERATOR - - Mr$10111111.01.11nraltintiriltlaWilnitiar GRil I F MESIIMainfaananatalitlianalli INFRARED HEATER S—a!s a flIDES ` l— LABORATORYCOCKS _a aa.SS ` laniallilla MAKEUP AIR UNIT las k-tt� '7`� s—ls FflE HEATER • Wil! FINAL'TEST AND INSPECTION TEST ROOF TOP UNiT • masses • Within five(5)days after plumbing wort is UNIT HEATER �' ' sufficiently advanced so that Principle No.8 In U o :i ,i 4 _n :' — _ _i 248 CMR 10.02(6)is satisfied,the plumber �, •_N. 5- who performed the work shall notify the m tiL!1l•argalfilicf_w■ —__a ins I ,, ,.,• ,, - R,,,l —i7— _ • APPGrants Initial:: .i . . tl W INSURANCE COVERAGE • I hay�a-&lnent T• insurance pa icy or Ls substantial equivalent which meals the requirements of MGL Ch.142 YES ['�NO LI I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - EMM Y INSURANCE POLJDYI OTHER TYPE INDEMNITY 9 BOND 0 OWNER'S INSURANCE WAiVEIt I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Lava,and that my signature on this permitbppllion waives this requirement. • ' CHECK ONE ONLY: OWNER© AGENT SIGNATURE OF OWNER OR AGENT • . - I hereby certifythat all d-the dells and Infwwanon I have sulanitted or entered regardng this am:M=5m are true and accurate to the best of my knowledge and that all plumbing work and htsmfa6om P permitaa be b wNt all Pertinent provision of the performed tmderthe (sated fortis epp(ka5on �PO� � Massachusetts Sista Plumbing Cods end Chapter 142 al the General Laws • f. • PLUMBER-GASti i I tH NAME I iW M79TH Err a S (LICENSE '—1 SIGNATURE * MPO MGF© JP❑ JGF© LPGID - CORPORATION EDI - I PARTNERSHIP 04 l Uc al - I COMPANYNAME4 Fel 1\'L-dine w$ (ADDRESSI(o' 0 -0 Bf3Et•Qst-)z ZiR-0 -1 • I CITY I Deo A.)15 • ( STATEI pip IMPa - - s TEL II-Coll-9e39' CO2S 1 • FMI ICall • ( {