HomeMy WebLinkAboutBLDG-16-000626 (7 r r /0 Ai"?c ei
MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
--4 -----
.V9' CITY,Tover-17f YA 1410 UT N I MA DATE 67/EURIEJII PETS 6146r-16 Va.)a26
._
. JOBSDE ADDRESS) 0 Pn-Lti-A,,,-Re.zi al, IMAM'S NAME j g,i I a i nkc
l.7 OWNER ADDRESS 1 - 1114@-of6 34 I - elrl 9 IFAxl 1
TYPE'Olt
Fitna OCCUPANCY ME COMERCIAL0 ECUC.ATIONAL 0 RESIDB4TIAL&
CLattRLY NEW:0 RENovinott 0 ReLACEtiiiird FLANS=Amex yEso NOD
APPUANCES I RDORS-* 1 esm i 1 2 3 4 5 I I' s $ 0 10 11 1 12 13 ) 14
BOILER ri .
BOOS
CONVERSION SUMER - ,
DIRECT.V811'HEATER
DRYER
FIREPLACE _
FRYOLATbR - ---
:
FURNACE I p .
_ . GENERATOR vr
GRILLE ---N -A
r A • •
III
INFRA -IRE)HEATH1 A • i
LABORATORY COCKS
WAPR AR UNIT . ....t . , ilb Lib • L, NO. WI 1
I
OVEN- : • •
POOL HEATER • I
_
ROOM/SPACE HEATER ' • •
diP 1
ROOF TOP UMT - , 1 , II
TEST i 1
UMT HEATER
IMVENFED ROOM HEATS • - — -- - i
, I • 7
• L '
I.
FASWIANCE COVERAGE .
I have a current*Nib insurance Why orb substantia' I equivalent which meets dm requirements of 111GL Ch.142 YES lidio 0
I FMB CHECKED YES.PLEASE INOCILIETIETYPE OF oiki r.K. BY OMENS. TIE APPROPRIATE BOX BELOW
UAIMMY INSURANCE POUCY le arHER TYPE mown,a -. BOND 0
OMER'S INSIMMICE WAIVER I am aware Out dm Iceman does not have the Insurance we required by Caper 142 reds
Massachusetts&mend Lass and thet my signet=on this permit VprmsCronaaves this mqtdrement. .
-.-
- OEM(at ONLY: =Net 0 AGIEirr 0
siGNATURE OF MER OR AGENT
1 haaby air*Ihstol des dada and kdaradas I ama atmled cr wand mgraeg ea appladon as 1rueard immeab la lad d my inadsais
and lid id piumblaa vast and Indablione pedomad undati pant Wad*reds appeadal al be In-•, • -.4400., - .1' pnnadon dee
illomeh000lo Mob Plionting Cods ad Chair 142 des Gonad Lava -Al, --K. _ _
....r,o,
PUMENER-GASFRTER NNE I gm;A In C-Br:rip. 1 UCEME ' , . 0 -- - - -•SIGNATURE _
MP la MGFD .IP 0 .1GFO IPGI 0 coRPoRA-notifilit .9 s&Y c,I pARTNERsir DO I de DO 1
COMPANY SAO 46yr-int-So at Plum 4 il cot flrlAbORESSI i I anek•cp•I atilt -• • 1
CffY ID.Y.....~14,4 la - 1 sTAIEDEEPPI 675 Pa, -
4 L -
Rikeerto-67861 .
•
, -
- - .
- -
: . • - .
- -
- .
"•
`1-