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HomeMy WebLinkAboutG-15-007 .-�y - . MAP: • : Pnag ePL __�` : MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I . CITY [_. - VAnm0UTP = MA DMEr77rER►�T# .-b/- CCI . • ' JOBSITEADDRESS( 99- Sin nra:sA U.cy (ONMER'SNAMEI G-y ainn: �. I • - OWNERA•UDRESS ( . . . • ITIIc�j S yoo-5400•,FAR - TYPE PRINT •OCCUPANCY TYPE . COAYdiRIALO • •EDUCATIONAlP . RESIDENTIAL((' � ' MARI'Y .NEW:❑ REN_OVATIOlt❑ .REPLAC :Ed:E PLANS SUBWir YES NO© _ - APPLIANCES 1 FLOORS-, 691 1 2 3 4• 5 6 I 7 8 9 I 10 11 ) 12 J 13J 14 . BOILER - - _ t BOOSTER . a, .— - __. __.1 CONVERSION BURNER COOK STOVE: . DIRECT VENT HEATER1111.DRYER - FIREPLACE ' . . FRYOLATOR • FURNACE GENERATOR • GRILLE — — — _, r- t INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT .. — ML__ M . OVEN POOLIIEATER ROOM I SPACE HEATER IIIIM� J r ROOF TOP UNIT t MM•SW ate• .TEST • — _ UNVFMm ROOM HEATER - _ 1 UNIT HEATER _ _ _ . . , . . OWATER THER a Pi oil. - ------ I have a ant Lability insurance pocky a its substantial min/walcnt which n dsU I i 1 1 I LSII • lherapmematsdN�IGN. !112 YES NO[,� IFYWDEp®YES.PLEASE INOCATE1WUPEOFBYg1ECLm1IGMAWOPM-E BOX BELOW BUI"IrdGDG Ili >� LJAMMINSURANCE POUCYCZAGE OTTER TYPE INLEMNITY D BOND 0 • OWNERS1LSURANCE WAIVER I mo arae that the Icenseerloesnot have the hmaance coverage required by Chapter 142 of they . MassacttsedsGeneral Lams,and that my signature on this P applIcatien Stills requirement. .' • CHECK ONE ONLY: • OWNER 0 AGENT 0 - SIGNATURE OF OWNER OR AGENT - I hereby ceay Halal onto defab and U tomud on I have Sri=or entered regarding this application era tna and a nnie to be best at my lmoWedpe and that a6 parking oak and Stabil=pa.Foanad mderths perm issued tort is appkatm r0 be In pile= al paovLion tt e Masadase@aSISP4anktand s142oinaa General m PIJIlsuRTfTER NAME( Kau MO R r:clam. • (UCENSE 1160 SIGNATURE • • MPErMGF❑ JP E3 JGF0 LPGID CORPORATION[.!)#rant C.(PARTNERSHBP04 (LLCDt - - • COMPANY wwE4 L',•1 Y1KBee/c. PIM 4 U e UI TnIADDRESS I I F.1c rsef Pok • ' I - CRY ( U) Ynrmr�,t.,,fb . I STATE DIA Z1P( D. IMOIMO ( rofs)-rr&-4556 -1. _ FAX( (,,, 1 f (iP