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Home My WebLink AboutG-15-2987 • ort enszn MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK lrit: CITY ;j' Aizmo1CL �---1 MA DATEI 1 rr c11t1 PERMIT X fl6/6 -aWfl7 JOBSITE ADDRESS 17,10- Tti P/N -W J OWNER'S NAMErA&1t4 WC cz-/,ZLAc 1 GOWNER ADDRESS17-57-4/14g. TEl(�&=7�j� FAX 1 TYPE OR OCCUP TYPE COMMERCIALLI EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:© REPLACEMENT:0 PUNS summit: YES0 NO[f APPLIANCES 1 FLOORS-* BG1 1 2 3 4 5 8 7 8 9 10 11 12 13 14 BOILER . 9 OI BURNER L wtr i ., COOK STOVE - 1 A P DIRECT VENT HEATER- -I „ ,. .. !L. - v - ii H.- DRYER a. -:o t .. t FIREPLACE p. �:� L FUFRRNACE YOLATOR y-;1 a s,- ' -4. : . p ;, , GENERATOR _ r a G WRIFRAREDHFJITER L. • ^• �— Lt LABORATORY COCKS - i " MAKEUP AIR UNIT �` ;4 „ OVEN POOL HEATER - - - 7 _ = - _ -ll'_ x -9 ROOM ISPACE t1EATER i - ROOF TOP UNIT ,. TEST �'_iti _wrc _._.r_... o- -} r,. .+n.. t _ - I ._. - --._ ^ _. UNchar-.., c•, - D -acro__ , 'mac, ,._ +_.._._---r-._ _ 1.. .. ..........1:4._.4; _._.4 W'Tr FEAT_R f r - ;� e 1 O 2-Q _ -_ 0 HES r# _ • / r - - - -._ - r if ) s sy. INSURANCE COVERAGE I have a current IiabMity hestrance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES O 0 IIF YOU CHECKED YES,PLEASEIN ICATE THE TYPE OFE BY CHECKINGTHEAPPROPRIATEBOXBELOW LIABILITY INSURANCE POUCY7 POLICY( OTHER TYPE INDEMNITY © BOND 0 OWNER'S INSURANCE WAiWit I am aware that the licensee does not haw the insurance corerape required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER 9 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have subnifted or entered regarding tie appkation we the and accurate b the best of my knowledge and that as pe et2 work and installations pertained under be carrel Issued for this application win be In compliance Pertinent proviski r of the Massachu efts Stene Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME If. --r LUt d� LICENSE i!(///y r SIGNATURE MP[Q MGF© JP 0 JGF® IPGI0 CORPORATION 04/1 —IPARTNERsHIP[D4C-1 LLC©# COMPANY NAME{ . .e . ,. Ar_,' i_ . ;Awns 025 Botorlair Rd . GCnr`f-/ 1 CITY - JIi,{St9 e_ _. STATEr ZIP O (o�g �TEL(St�'t/77-��7 . FAX f i CELI.175- -'n AwaitI In . / • /, - t.. _ _ • - _ i ✓.