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HomeMy WebLinkAboutBLDG-15-003480 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .,__' MA DATE �? S 4 .PERMIT#f�Df1-/SOd��IS ' =ems' CITY : ttA �--. Q(� _ __ i__ ---- ••--____------ ______ G JOBSITE ADDRESS'C OAII/Yhvn c E d�OWNER'S NAME I 42I t/4 ___ �.__ OWNER ADDRESS E /( t(� y (TFI:•77if•e17U:61.7C• TAXI --_ • TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Ti RESIDENTIAL„-= PRINT r-;c — —• CLEARLY NEW:+ RENOVATION:...] REPLACEMENT: �: PLANS SUBMITTED: YES'_, NO;, : APPLIANCES 1 FLOORS BSM 1 ©©gg 5 6 7 8 9 10 11 12 13 1 • BOILER Niiiinfliat int la Mt ilitilliiiitilinitillifillitilill - BOOSTER _ SSIIIIIIISIONMetinitint_ I CONVERSION BURNER itiftislawainSisrpm siant. COOK STOVE m-SI MI SS ISSIIIS allistin muilmine I DIRECT VENT HEATER Ininit SS. - SS OW DRYER Walt: Wat O' - I FIREPLACE miis Mgon sinelillestialfai' FRYOLATOR J1.010.1-001.01.4011. 111011010111111.111.01•111111_ FURNACE S r GENERATOR encs—sot itailitIMININIONONIF ilia . GRILLEW ; OBIS INFRARED HEATER NoteammatitiOSSSMISNIOSIMP LABORATORY COCKS gisiininit -ilio __ ! MAKEUP AIR UNIT 1111.11.SiiilliptasimilinitSISIMillallete OVEN ! S _SnS- POOLHEATERSNS ROOMISPACEHEATERimi SS MS. semi ionNSHMS ROOF TOP UNIT an .MS; liaS TEST i ow OM MI -•. _ `_ I UNIT HEATER wAr_• - p 101110saniiassitasisiONESSINWIIIIMOIr OTHER. D 7 B 11a i us; 1S OSn- SS S --DEC-1-9-2-0114- _-til__. __■mac_ �■II�€_ _ I -BUN_____ iIdL MC INSURANCE COVERAGE - By — vL' which meets the requirements of MGL Ch_142 YES NO I have a current liability insurance policy or its substantial egt+Iv� I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 7 BOND U. OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Law;rand that my signature on this permit application mves this requirement • CHECK ONE ONLY:. OWNER 3 AGENT I SIGNATUYIE OF OWNER OR AGENT i a and I hereby certify tat am of the details and uttantahon I have stunted Ore for regarding applicawition u curate Et tthe best of y knawledc and that all plumbing work and installations Pian utter the permit Massachusetts State Plunking Code and Chapter 142 of the General Laws. r. .t•C L---- PLUMBER-GASFITTER NAME J�/L R tE L,FE1c3cir> j LICENSE#1!i SIGNATURE _ MP MGF ' JP JGF LPGIL' CORPORATION# T7(' I PARTNERSHIPj _;i1J— LLC W#:,___,•- commit(NAME . ) 0/ met rie-tfr /C ADDRESS' 13 L/nedn AJF _ __� `- r�a CITY •p/f}t/1YiII1 I STATE;1p� IZZIP 0)ZE„2_�TELISCR^G!f-`fTi5-1 --- FAX 47?____ CELL__--_____.'EMAIL'- —r :..:, (� S3.LON M3IA3N NV1d • H 1I1N113d $ :33d ❑ ❑ iM1Alli3d 3H1.SV S3A113S NOIjV3I'1ddy SIHj oN `alt . . . - S3.1.ON NOLL/3dSNI '1VNIA A'INO 3511 1.101J3dSN1110A 39Vd 51II,L S3.I.ON NOIJ,J3aSNI SV7 linno f