HomeMy WebLinkAboutBLDG-16-002400 �'I A.0 p,9 R c e,/
.. _MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_ '- CITY!Tow of Q o I j_ f MA DATE 1 •
/. PERMIT# 614 P I(o-OCI oZ 140
• JOBSITE ADDRESS! v0 11't e r I./). OWNERS NAME ♦1 c?rr 1 l LAr.Q_
• G OWNER ADDRESS -
TE] so5)76G 2375 FAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YESD NOD
APPLIANCES 1 FLOORS-1. 1 BSM 1 j 2 3 1 4 i 5 i 6 J 7 ° B 9 10 11 1 12 ( 13 14
BOILER -
BOOS1 t.R
CONVERSION BURNER
COOK STOVE
DIRECT.VENT HEATER 4
DRYER - - i.: _ I
FIREPLACE -- x.- 1 a__-- ._ _vv-
FRYOLAT'OR = s
FURNACE
• GENERATOR _
GRILLE —° --- - ;
e Nelt Au _.
LABORATORY� COCKS � - - �- - • , � -- i , � arie
MAKEUP AIR UNIT —4 HEATER `` = ,i •_ r y i - NO.: to
/ .. - J
POOL HEATER - .
ROOM I SPACE HEATER - ,
ROOF TOP UNIT • - � . =
TEST -
NIT HEATER
e lin
UNVENTED ROOM HEATER
_WATER HEATER .. A' - e — - -- - - --
OTHER I - - -
INSURANCE COVERAGE
I have a current Ralik insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES IL NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY Q( OTHER TYPE INDEMNITY 0 - BOND
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 permit application waives this requirement
• CHECK ONE ONLY: OWNER D AGENT 1:3
SIGNATURE OF OWNER OR AGENT -
I hereby certify that al ante details and biksrna&an I have submited or entered regarding this application are bur and accurate folio best of my knowledge
and that all plumbing work and loons performed under the pent issued for this applcalon wil be in-• t. , -- . all of+entprwlsicn of the
Massachusetts State Plumbing Coda and Chapter 142 of the General Laws. _ ® �/
PLUMBER-GASFRIER NAME 1 kev,n '
' � �f:�p� �LICENSE :- i I bn?0 _ , SIGNATURE
MP� MGFQ JP® JGFfj LPGI0 CORPORATION a 86s C..!PARTNERSHIP !11C DOI
COMPANY NAME n-rncB rr de. Plum 4)1 izef.0, ADDRESS' I 1 eP4• Pa l-A
• CITY W. ye,r nnc.-FJ • STATE IM21P1 Oa•673 tTEL l (5AO 4 554 I •
FA ofr)7go-5785j CEL LI lEMAJL -
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