HomeMy WebLinkAboutBLDG-15-001720 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY : jQ.IQn1oa /- ; IM DATE r-. 974/0‘
S/Et PERMIT# 6715'D0/l v
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JOBSITE ADDRESS •y_c_p2_t n 42e- —i �..EeQS.�_—
GOWNER ADDRESS -7 �I ti - 1 TEL10&-4K.LI 0 !FAXI - -.
TPRIYTR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL. s RESIDENTLAL J -
CLEARLY
NEW:. RENOVATION:L S REPLACEMENT:- . PLANS SUBMITTED: YES;J NO
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 s 6 7 8 9 10 11 12 13 14
1 BOILER Miniilligiii
BOOSTER .. .:>SWEIE
I CONVERSION BURNER
STOVE 4
DIRECTVENT THEATER __
15 -
DRYER aI SI _
' FURNAC OR � �____��
` FURNACE _- - - -
GENERATOR
all BE Mile=
INFRARED HEATER le ja
..._
LLABORATORY COCKS _ OS ii.MSOM _
I MAKEUP AIR UNITf> MINA NM _ SA .."'-
OVEN ' Mini � -'
POOL HEATER _ MINIONICII_OM
ROOM I SPACE HEATER _ ._ .__ _ isillim Es =_ .#
ROOF TOP UNIT ._ _ __--_ s
TEST _. _ _ - 1 .
UNIT HEATER L
UNVE r e :ten . I -an- -ma
WATE - - 'r-E .9 I .— � �/an=aillin_
OTHER: +� _ _ - _��� � -.
aUlrirrr�v = INSURANCE COVERAGE
e"' which meets the requirements of MGL Ch.142 YES NO '
I have a-,�[t1.liabil � �+� � .. cy oras substantial equivalent
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCYX OTHER TYPE INDEMNITY J BOND L_?
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 r•AGENT 7_
SIGNATUrtE OF OWNER OR AGENT a
I hereby caddy that as of the details and nromma6wi I have submitted a entered regarding this application are hue and aminate to the best of my knovdtedf
and that all plumbing work and installations perfomred under the parts issued kr this apvfrati?n will be in compliance • l.ertineM provision of the
Massachusetts State Pi mbi g Code and Chapter 142 of the General Laws- t ` - t T--
PLUMBER-GASFITTER NAME Piiiizi A eGto A/ i LICENSE Bl iti SIGNATURE
iMPX MGF_. ' JP JGF_" LPGI[J CORPORATKMI3J#iat#77e I PARTNERSHIP;";# — — LLL: ]#`
COMPANY NAME:4cy ;J /an}t,f1E-r& ft‘lADDREESSS , O3 cczk _ __._
CITY PIf uT t%flls" STATE , EZIP Ze,Z ITELrcc -an-ris-sq - -
I � [I FAX rf Sc6 CELL: — IEMAII' c. v .. A. _ i �. 4: " e A.`P T
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