HomeMy WebLinkAboutBldp-20-003161 (2) f}P �� c e /
_ MASSACHUSE i 1 S UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY [Town o1 VA R,61 D ti I-1 f MA DATE d -► q 1 PERMrrit OaP-Io-O03/ l
• JOBSI 1E ADDRESS! 4(J 7 /7+ 1 ,72Ge D . 1O VNER'.7 NAME! -/-)M Er, l•lJr,n
. GOWNER ADDRESS I (T E1c 514-07df)FAX _
TYPE DR OCCUPANCY TYPE COMMERCIAL U EDUCATIONAL 0 RESIDENTIAL.if
PRINT
L'T R R7 Y NEW:i RENOVATION:0 REPLACEMENT:III PLANS SUBMITTED: YES 0 NOD
APPLIANCES 1 FLOORS-4. BSM 1 2 3 4 5 8 7 : 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
_ ill ill
COOK STOVE - .
DIRECT.VENT HEATER --a -- -
DRYERIII
III I
REPLACE -� _ ---
FRYOLATOR 1 2
FURNACE
• GENERATOR
GRILLE II
• 11+FRARED HEATER no
.xr.'Rpm
LABORATORY COCKS , , ,..MAKEUP
�/ AIR UNIT iiyp- iiiii ' 1�i►1 •r• ,
OOVEN - - -.,•. I ,i -..r I 1.." 1 - _. I7 � '
POOL HEATER • 6W_ y ' _ ' - . u
ROOM 1 SPACE HEATER
ROOFTOP UNIT -
TEST III
UNIT HEATER
UNVB4 ED ROOM HEATER
1 OTHER ---
INSURANCE COVERAGE
I have a current Betray insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES LNO Di
I>F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY d OTHER TYPE INDEMNITY Li BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massactutseds General Laws,and that my signature on this permit application waives this requirement.
• CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT -
I hereby certify that al rt the details and information I have submitted or entered regarding this application are True and accurate to + -best of my knowledge
and that all pkrrnbing work and installations performed underthe permit issued fortis apprrcaton will be in - -_ . provision of the
Massachusetts State Pkanbing Code end Chapter 142 of the General Laws - . lik -
PLUMBER-GASFrrrER NAME Ikeu;IN 1Y)c&&:rip. IUCENSE#I 1 Httaoi - -= - SIGNA11JRE
MP a M GF EZI JP J JGF C LPG![J CORPORATION 6a 8(.78.C.4 PARTNERSHIP 0 1 Llc jam. I
cOMIPANY NAMEi IC(Yl fc de. (}Ronk 4)4,. ..i Ei1c, ADDRESS i t I ncjmoc a IAi-A
' CITY (.U. V:rfAnc.-F1 • 1 STATE ZIP ♦ . 6 3 rio.7•2-01..•Bell Jtwe •
-
A,N t -6�85 CELLIspjaidu, 7AIBAAILI km c p l u r-r. p 6 c.n en GAS' a5 e i(
I
1
. , .
p 4�:',-J r-. - .L N i 9 x
4 y
• •
a �