Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
G-14-796
rim/0 °ArP c ei al t y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Lli .sr _sc= , . . �' _-h: ' CITY,Town of ,4 W nil O UTN i MA DATE 7/C►Qa PERMIT# Mk 71O 11.1 at,,w a . JOBSITEADDRESS! 7 S4/ r)-tnrJ I n IOWNER'SNAME L ({J,'.,40n nrjoinn l () tm - OWNER ADDRESS 1 • (TETl (FAX W LL R OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL0 RESIDENTIAL IY CLItIktY NEW:D RENOVATION:Q REPLACEMENT:❑ PLANS SUBMII ItU: YES NO APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 • 8 9 10 11 12 13 114 BOILER - 0 9 4 BOOSTER CONVERSION BURNER M1 .' fl_" '.., '1'f_ - - COOK STOVE DIRECT.VEN=HEATER erg aa _ i DRYER ink»,1••1i eirS — FIREPLACE �M11:W �:>t M' 1: 5 FRYOLATORSan�_ � �.ON W _ — FURNACE menn __,S • . GENERATOR GRILLE I r IWIRINIKhlieriti- - INFRARED HEATER LABORATORY COCKS 1.1111111.1.101110 Mr 101.... 1J„11_}lWL7't1I .4(st.W ii&U&'1%4U MAKEUP AIR UNIT --a--=—fl441LS.i,;mnrt►r,{Lh sa 1 4I1L4 Acr•A a I OVEN• MOM 1.11=111111)1MINth+i7laVLZIMal A71L-�'JLI!dL:W1F _ - POOL HEATER ' NWlam_—:= 111rr1iL`'W±l'1_:Bi lata/1.1i L' 1411L _ ROOM/SPACE HEATER pm Am __umAmlo :--a 'F •�, •_llE111 ROOF TOP UNIT • r•' TEST en.._ ._ _ " tear UNVENTED ROOM HEATER Sire Salina 11� UNIT HEATER - ) �_ �'__ _' s_' -WATER EATER _ - `]I ours i )C-1-7 — ii 7�(l(�1- 1) • .. • 1 III t lit el T I INSURANCE COVERAGE I have a current liability insurance policy or Its substantial equivalent with meets the requirements of MGL Ch.142 YES ®NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY© OTHER TYPE INDEMNITY'© • BOND Q 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 Ci AGENT 0 SIGNATURE OF OWNER OR AGENT , I hereby certify that at of the details and Information I have submitted or entered regarding this application are true and accurate to . e best of my Iomowledge and that all plumbing work end Ins-Wagons performed under the penny Issued for this nook:E don MA be In compliance with a6 P- ' ad provision of the Massachusetts State Plumbing Code and Chapter 142 af the General Laws. A� PLUMBER-CASE- I•ER NAME J pry;, In c2 r:tie. (LICENSE :• I I bnl O s , SIGNATURE � - MP a MGF❑ JP© JGF Q LPG!C3 CORPORATION rail a •,6•• G PARTNERSHIP� (LLC U# COMPANY NAME: IpvunmcBrratPlum-tNetSi1cIADDRESS I II LfneJr.Sr} P�-h q • CITY W. Ymentnr.-}I+ • STATE rail ZIPS 0873 ITIEL I (5601*- 4554 I • FAO-o8)7ao-67III ce.4 (EMAILI_ , I • . • G2ft 2/e !f 6>2-3 tri- 01/A(1/2--/ •