HomeMy WebLinkAboutBLDG-20-002335 .QI.. _ MASSACHUSE 1 15 UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
n CRY;Town of 14E7 i.z 1.1 3 MA DATE, a_ �p PERMIT#/,C� 3 f
JOBSfTE ADDRESS! •�SC is r�' � 1__ S OWNER'S NAME 1 D0 -;r k..co I\ ,. i
OWNER ADDRESS • I TQ4-7741 13. -11'7 I IFAX
BUR OCCUPANCY TYPE COMMEREIALLi EDUCATIONAL 0 RESIDENTIAL°CLEARLY RT Y NEW:D RENOVATION:0 REPLACEMENT:L"I! PLANS SUBMITTED: YES[J NOD
APPLIANCES 1. FLOORS-+ BM i 1 i 2 3 4 5 5 7 , 8 g , 10 11 12 13 14
BOILER _ ,
BOOSTER -i to.— ., ...,,.. ..
CONVERSION BURNER
COOK STOVE - . l ,
DRECT.VENT HEATER -� i ,a _
DRYER , -- l
FIREPLACE
FRYOLATOR - _
FURNACE r Js
• GENERATOR -
GRILLE i : I. t i . la .i - • :l w.
• INFRARED HEATER
LABORATORY COCKS moil
MAKEUP AIR UNTT b r .ut• • 56 -1 . . . Ifl
r
OVEN' — 1 I _ + : , _.
POOL HEATER • _ .rr- n }IC ' 1
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVNFE)ROOM HEATER = -
-WATER EATER -
OTHER
INSURANCE COVERAGE
I have a currert frdbillly insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 1NO 0
IF YOU CHECKED YES,PLEASE IM)ICATE THE TYPE OF COVERAGE BY CHECKING ITIE APPROPRIATE BOX BELOW
UABMY INSURANCE POLICY Er OTHER TYPE INDEMNITY® • BOND 0
OWNER'S INSURANCE WAIVER:I am 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 punt application waives this requirement
• CHECK ONE ONLY: OWNER Ej AGENT
SIGNATURE OF OWNER OR AGENT
I hereby cerWy that al rifle details and infonnali n I have submitted or entered rung this apprcalion are true.and amine 10 -best 0f my lmewiedpe
and that all Codeplumbing work and and Chapter performed urderthe permit for this application will be in compliance i -' - _ provision tithe
thassachusedas Slate Plumbing mph 142 0f the General Laws. _ �/�,/. -
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PLUMBER-GASFIT'TER NAME y k ,r, In CB f•pie_ I UCENSE#j i 169 Q - '- - - SIGNATURE
MP i1 MGF 0 JP 0 JGF D LPG!D CORPORATION rista il(, C.1 PARTNERSHIPDVI 1 LLc a ism
COMPANYNAMEivvNr-m rtde. Plum 4.)1 - ...ncl ADDRESS I, II r i-nclocAl PezritircrivED i
CITY LU. �/,,.„-.y,"LA-1, • STATE MUD2PI 624.73 ITELLget- T7$-'A554 .
FAxrotrj7ao-s7$5l CH.USok 3bM37d41E1 -I�M cp I V ryy 6 c:.f)rn ccts , r��D T 2 4 2019
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