HomeMy WebLinkAboutBLDG-15-001964 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CJOBSITE ADDRESS y' iv,;, <nrn ' /c d 'OWNER'S NAME 0,,S n /3 C,<r 10tell
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‘t) OWNER ADDRESS L+ z, L,, con( 4a TEL 1FAX : I
P PE TR OCCUPANCY TYPE COMMERCIAL EI EDUCATIONAL D RESIDENTIAL E�/ I ,
CLEARLY NEW:❑ RENOVATION:[ / REPLACEMENT:❑ PLANS SUBMITTED: YES® NO❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ' ip {. 1l 1
BOOSTER 1 '' I �,I fL . >=, =i
CONVERSION BURNER I —141 .. it , ,,,,, L_
COOK STOVE a ,1. _ .y t #. i 1 ,
DIRECT VENT HEATER 1 I I II 9 I, li-- II
DRYER 1 —`-
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FIREPLACE r,,. I
FRYOLATOR
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FURNACE f f,._ I 1j` -` � .m. I . l � .'!,�� f I )
GENERATOR , 1 q I t
GRILLE �_3 ;, _ Iri., 11j1 R I !
LABORATORY
MAKEUP AIR UNIT iTJr i 1 it , . •l .
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POOL HEATER
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UNIT HEATER _ -ti 1 f1 s
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__ ..____±.L_1 INSURANCE COVERAGE �,,(
• •- a e olic or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO Ys
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY U . OTHER TYPE INDEMNITY] BOND 0
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0 iER'S INSURANCE WAIV :I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
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G eral Laws, nd that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER GENT Q
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance wit A all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
‘PPLUMBER-GASFITTERNAME G I - K ' LICENSE# r, j S ATURE
MP al MGF0 JPE 'JGF0 LP IQ CORPORATION[#j IPARTNERSHIP 0#- LLC Q#I
0,,. COMPANYNAMEIe.0,o TA,,,..if• pi,,,,,4,4A ADDRESS 10 z Un r tinr J
CITY L7 - 11 R l r- ( STATEf 4ZIP 02,6,7 S— TEL cot-- er z2- Li.ooil
FAX 1 CELL Sc.., f 'EMAIL
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