HomeMy WebLinkAboutBldg-19-004396 , _f+ _ . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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r 1• cr 1 '/ R-AcV ( - • MA DATE //7--,('/ 9 PERMITS i3Ln17-/?-60'/9
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JOBSITE ADDRESS.07r-- 'W:f F111.3e.. '/'S 6''� • :OWNER'S NAME
M<! )V 4 l /lam
G OWNER ADDRESS 1,1 TEL • FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAy,g,
FREW
CLEARLY NEW:S.— RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPU ANCES Z FLOORS. 88M 1 , 2 , 3 , 4 , 5 6 7 8 9 10 _ 11 12 13 1
BOILER ,
.BOOSTER _ •
CONVERSION BURNER
COOK STOVE '
DIRECT VENT HEATER • .
DRYER .
Fes . _ .} •
FRYOLATOR
FURNACE -t
GENERATOR _ .. ' c.k a ,
GRILLE
INFRARED HEATER ; '�_� >� ` �I
LABORATORY- COCKS . �'!': - :.� � - • -
,P3w, ;�a
„MAKEUP AIR UNIT r. N n"" y
r POOL HEATER
ROOM SPACE HEATER ♦ '.
-,,..:\ ,•.., ,_,. it...c . ._
ROOF TOP UNIT I `
TEST .
UNIT HEATER . • •
UNVENTED ROOM HEATER • _ ,
WATER HEATER .. _
-
OThER
J _ (0NGU6�'-T
!►�aP 7 4j(J1‹ ,
•
• • ININJR ANCE ERAGE
• I haveacumntilabnir insurance poly or lb substartld egldvaleRt which meets the requhsmenb of MGL Ch.I U YES*.NO ❑
I IF YOU DECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW' "'
LIABILITY INSURANCE POLICY Jg. OTHER TYPE INDEMNITY 0 BOND 0
OWNERS INSURANCE WAIVER:I!tee balm that the licensee Aftnithin the insurance coverage required by Chapter 142 of the
Maeaadhusei(Cameral Las and that my signature on this permit application yeng this requirement.
• CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
WON', I ON' .cuil that all Atha details and hibmwiori I have submitted or entered regarding the ' era trw and accurate to my owledge
and that all plumbing work and instaWdiora performed under the permit Issued for this application will be compliance allPa tent of the
Me achusetls Stale Plumbing Cade and Chapter 142 of the amoral Lam. v,//I `'yam_
PLUMBER-GASFITTER NAME A(m-Ate-zbizize.„„...._ LICENSES((s-j SIGNATURE
MP 0 MGF❑ JP 0 JGF 0 LPGI' CORPORATION❑# PARTNERSHIP❑# LLC❑S
COMPANY NAME .7.4,5 I-E3 IV ?gin 4J ADDRESS IP•4• Veer o / Za '7
CITY 5, `, A11 i 13 STATE M$ zip oo�li66 TS,'07?(pd ca:?74Y-
FAX 7/et.' l933 CELL 5 ,�? I7yfL EMAIL/111,19 7Rtri C g 4}S1 pA?• 0.0-1/
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