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HomeMy WebLinkAboutBLDG-15-002246 .3'v Vk (%YQ 3 i i+ E j ,i. . .- - e > .... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK =r, °°I_= CITY r._ foV►►^r vF.r. I MA DATE' Io/ 9// I PERMIT# 1.�776/5--O0ol.2 / JOBSITEADDRESS' /( ' # 1r1'I h I) r l OWNER'S NAME i i 4- --f, p-c7 .I GOWNER ADDRESS . ,spwk,e _ I TEll IFAX r-- - _-1 TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL(l RESIDENTIAL( ' PRINT � CLEARLY NEW:® RENOVATION:El REPLACEMENT:Glr PLANS SUBMITTED: YES NO© APPLIANCES 1 FLOORS.-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER ._ SMIIIIMMIIIRSE511^_ IUD CONVERSION BURNER IIIIIIit COOK STOVE DIRECT VENT HEATER 11111^ . —- _ _ DRYER ,...FIREPLACE ,Mil ill _ _._ _, , 1 FRYOLATOR Illy Ill FURNACE _GENERATOR Mg ON MN MIMI 01111110 OM ME Mill imp normum um GRILLE INN NMNW. .� 1, INFRARED HEATER unit IMAM IIIIII NM NMI MO MOO NW LABORATORY COCKS AM MKMN,NM rIMITIMIIN NM lNMK ma pmow ling M 1 1 _ MAKEKEUPAIR UNIT 1��;���� ��..�,i�, I '� e_. I .-. POOL HEATER ,, ROOM I SPACE HEATER _. :I no ra- t ROOF TOP UNIT TEST ow 1 UNIT HEATER N M ! 1 , ___ ;r ► ;!- -�. UNVENTED ROOM HEATER NM JINN i OW Oat ll111111 '1 WATER HEA ' .r I — �! / INSURANCE COVERAGE �,� I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES i., o El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY HECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND Q 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 signattxe on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are tyre and scours to the best of my knowledge and that as plumbing work and Installations performed under the permit issued for this application will be in comps h anent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER-GASFITTER NAME /)I ,' f c/t o j LICENSE# `!0!S` S _ SIGNATURE MP MGF® JP 0 JGF© LPG!® CORPORATION Ikjirp l�!' PARTNERSHIP®#A J LLC D#LI i COMPANY NAME: CiA9�6/CvQ Ku-La,.-� t ADDRESS QS rrJ �vh _ 4 a4..-- 1 CITY [��rv. L p✓'t^1�y Yl, -.. L4o4-__J STATE N t.a ZIP( O�-fv(d-� ITEL I S-19 p —3 get —730/ I FAX '''0672( I CELL[ ls8-1f30a-jEMAILI �ch �1 - 7s-70 Cjf