HomeMy WebLinkAboutG-19-3228 - Alke: PIUGE I-•
_ _ MASSACHUSETTS UNIFORM APPLICATION FO
R A PERMIT TO PERFORM GAS FITTING WORK
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=` -f,` CITY 1...._S„ ,r ��,� MA DATE���, a„�,,,,,)PERMIT# a �� g
JOBSITE ADDRESS 1 � �I OWNER'S NAME w� ,��.,, ,
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TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL D�-•� RESIDENTIAL
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Ilr PLANS SUBMITTED: YESD NOD
APPLIANCES 1 FLOORS-4 NM 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOILER INK I .L.11 .11011011101100110010101I -
BOOSTER 11 11►I T1111I .011 1 I!r l�lffl�J R1O E 1 l F ..
CONVERSION BURNER 11011111100101.1100110111111111.91000j10011001111001.1101010110111011111111101111j ..
COOK STOVE all,1 I l 01.1000.001010Miliaii� J
DIRECT VENT HEATER imoomornotola, iu1Iiiitiii.►iiipo! ow 11 ,
DRYER Ma Mil iiiiiii iiiiiiMillilli' lilifillitilli 0001110111111011101111.11
FIREPLACE
FRYOLATOR
Il (I IIMIN OPPI [IIIII 1.1.11.1111111111110.01.11.111111110001
FURNACE •* I I I i LM Ili _ 101 l 1 _.,r
GENERATOR ,! . l� .....
GRILLE T1li� ^ I /� 1
INFRARED HEATER I I lot- s( i ]
LABORATORY COCKS A ilt0_j Il _ j .. ...
MAKEUP AIR UNIT ,0010/00I1100; � ,`
OVEN � �
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POOL HEATER 1�. �.,. 11 1 1
ROOM/SPACE HEATER ;00.1J j( jf I NI
ROOF TOP UNIT 01101111011010.14.011110.111.111.101. 01111101.1.11111010110I I1 I I
TEST iiirl1 NS I .. ...
UNIT HEATER ri 101.10.1.I;i 11 1j 10 N ..1I01]
UNVENTED ROOM HEATER J4I ( !
WATER-EATER
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INSURANCE COVERAGE
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL,Ch.142 YES UNTO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY -" OTHER TYPE INDEMNITY 0 BOND 1:1
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havq 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are tru nd ac rrat Ito the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in co a ripe fh ait:Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. z�-
- - ,/fra SIGNATURE w
PLUMBER•GASFiTTER NAME���„ .�,� �,��..�- �LICENSE#�T „I
MP MGF 0 JP El JGF 0 LPGI[J CORPORATION I ! i PARTNERSHIP)# LC #I -....
COMPANY NAME:g . r , ADDRESS " . it� r
CITY n 3c ..I.��..1 STATE �'�JZIP r . r TES. ® - G ,,;,,,,,,,,,,,,,,,.,f
FAX aaar 7SjCELL[9 ..-. �2 EMAIL, 5l i,, ; .t...,gad, ts‘G...1.;fe.i...i..r i_.........:
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