HomeMy WebLinkAboutBldg-19-005796 ". MASSACHUSEfTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS.FITTING WORK
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CITY )14n.e o,ri t7 MA DATE 3 /ill I PERMITS —6"d 5--77p
JOBSITE ADDRESS i e i I r`cc_ I �n/ OWNERS NAME P
3 54t1I f 1 n 5
G OWNER ADDRESS TEL FAX r --
RESIDENTIAL[V \ 50,00)
TYPE OCCUPANCY TYPE COMMERCE❑ • EDUCATIONAL. ❑
C AKI' NEW:0 RENOVATION:0 REPLACEMENT:[ Y PLANS SUBMITTED: YES❑ NO'
APPLIANCES Z FLOORS um 1 2 3 , 4 , 5 8 7 , 8 8 10 , 11 , 12 . . 1s
BOILER — -
BOOSTER -
CONVERSION BURNER
000K STOVE C.on IL -co v' 1
DIRECT VENT HEATER
DRYER
FIREPLACE r - •
-
FRYOLATOR — -
FURNACE 4 .
GENERATOR •
.... .... _..
GRILLE R r c F i '‘ ,k (t
INFRARED HEATER . .
d�- _y
COCKSS a
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MAKEUP ARU - Aft ��� U 1
OVEN . . 1 , , ¢ . ,
POOL HEATER �.,L;�,c `-PA.R T M�_�" ' }
ROOM!SPACE HEATER 1-L
ROOF TOP UNIT ,
TEST .
UNIT HEATER — - ���
UNVENTED ROOM HEATER -/ v - -
WATER OTHER HEATER = 4pR 0 8 2�9 _
0 44RTM-�
• INSURANCE COVERAGE
I have a current Witty Insurance policy or Its subetWElei equivalent which meets the requfrsmsnb of MGL Ch.la YES NO [
I IF YOU CHECKED YES,PLEASE=LATE THE TYPE OF COVERAGE BY CHECK=THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IL7 OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee gagmtjuga the lnwrana coverage required by Chapter 142 of the
klaisachissES General Laws,and the my signature on this permit application gigs this requirement
CHECK ONE ONLY: OWNER 0 AGENT
SIGNATURE OF OWNER OR AGENT '- '.
I herebythat
�lu thenep Pador enured r ell&drop thug ep os,ad� +W to the best of Pertinent prevision of tt
and km
�all under the penmR Msuad foe. appibetlon will he
usetbs Sate Plumbing Code and Chapter 142 of the General Laws.
PLUMBER=GASFITTER NAME ci/4 N 1/1 6 10 4 r el UCENSE#11/77 ' SIGNATURE
MP reMGF 0 Jis 0 JGF 0 LPG(0 CORPORATION IeS PARTNERSHIP❑0 LLC❑it
COMPANY NAME C.�je . add ?i upt S,M4 4 kli 4, ADDRESS f O. /S.vX 41.1
CITY S ew tl' STATE L ZIP p? << eEIAA TEL 5 e P.- 314P —t L
FAX CELL. '
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