HomeMy WebLinkAboutBldg-19-003509 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
=Gi_ CITY _ MA DATE PERMIT# 4U' `Uv
JOBSITEADDRESS r_ OWNERS
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TYPEPOR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL&
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CLEARLY N EW:LJ RENOVATION:D REPLACEMENT:g PLANS SUBMITTED: YES` NO D
APPLIANCES 7 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER �.._; i --'
BOOSTER •
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CONVERSION BURNER -. IL- I! UM, I___ 1- ,. -
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COOK STOVEr.
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DIRECT VENT HEATER __' ' _, _ _____;MEW
DRYER i_
FIREPLACE L.
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FRYOLATOR 1_ __ .y,. 1�_ __ _ a aI_ .«..._i.,` _ _ _
FURNACE . _;C. � _ ir......___:,. ...._„_.
GENERATOR . .„ . ,TM �_,.4' ';
GRILLE 4,,,.. _.�_. ` „ , .. 1;
,. .... _ tip.
INFRARED HEATER L_ I �, L I E
NW
LABORATORY COCKS I
MAKEUP AIR UNIT ; ...t � �`R ': ._ --1
OVEN s1.: _ _____,!
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POOL HEATER x« _ MINE
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ROOM 1 SPACE HEATER -- i r,_..
ROOF TOP UNIT ;, 1.... I� �: � 1[ I
TEST ' t 1 — -. ��. (W
UNIT HEATER �-� _�
UNVENTED ROOM HEATER w ; { '...-- 111111
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WATER HEATER ., ... `4_.�._-0 I
OTHER ; ' 1`L-__.. -F..,-_ ` _-._ __IIIh `
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%._. �,d...w..�.- - ,. _.. .._ry., INSURANCE COVERAGE. __ _...,_,�_�w.,,. -.
YES NO
substantial equivalent which mee
ts the requirements of MGL.Ch.142 t.,;; I
I have a current liability insurance policy or its q �I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY BOND r
OWNER'S INSURANCE WAIVER:lam 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 AGENT D
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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. al f.-\
PLUMBER-GASFITTER NAME Crai�q Bishop j LICENSE#'15101 SIGNATURE
MP= MGF JP JGF I j LPGI,_,,,j CORPORATION Litt d }PARTNERSHIP D# ,- „,. '{LLC r ___.__
COMPANY NAME:High Efficiency [ADDRESS 378 route 130 .. t
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CITY Sandwich 1 STATE - Ma I ZIP`02563 tTEL L _ ter. .. .._-.v. «.._ :1
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FAX' CELL IEMAILladminSa high-efficiencyllc.com
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