HomeMy WebLinkAboutbldg-20-000700 �, /sl%i° ��Jr�'c e /
_ MAS ACHUSI i is UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY Limn of Y MA DATE,87 /I95 , PERMIT# 0/� (�
JOBSTIE ADDRESS: 1)(-, R C�epryr,�I/ PO'.n-f Oc I OWNER'S NAME I ve
OWNERADDREss 1 • j TELi 4 13 5 3)—Q 43FAx) 1
TYPE TOR OCCUPANCY TYPE COM1IEREIALD EDUCATIONAL 0 RESIDENTIAL
CLEARLY RT Y NEW:Lj RENOVATION:to REPLACEMENT:
PLANS SUBMITTED: YES 0 NOD
APPUANCES 1 FLOORS-. BSM i 1 2 3 4 5 6 7 , 8 9 10 11 12 13 14
BOILER _
BOO61 tit
CONVERSION BURNER Mit ')111111 MIK MI A RIK—'MIN —
1/11/ff MEW Mit*tit
COOK STOVE
DIRECT.VENT HEATER
DRYER
FIREPLACEI III III
FRYOLAT'OR '
FURNACE
• GENERATOR
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GRILLE
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INFRARED HEATER .i P._ mitifami.11101;I• II 1
LABORATORY COCKS 101.11111111 —1L1t:t. iL u I,:7 " , .L:,j11.4 L'.:1I• TA:ill&:.
MAKEUP AIR UNIT MINI MI Mr M W h _1eiriva •AA
OVI l' imur!MS 11111111111111111111111F11111114iif 1;i411 _GLi /1i1;/:.wi., .tl:�:',2.1.LAlt
POOL HEATER _ T
ROOM 1 SPACE HEATER - _Mt L r' iha h �'i IN
- _-
ROOF TOP UNIT • :-�it, � �:-
TEST I .
UNIT HEATER
UNVENT D ROOM HEATER
-WATER
- OTHER -
• - - _ _ -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES LEINO 0
i IF YOU CHI YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY I OTTER TYPE INDEMMTY 0. - BOND LI
OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Masmichusetts Getwsral Lairs,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 an of the details and irdonna6on I have submitted or entered Faga�ieg this application are true and accurate to ; best rimy knowledge
and that all plumbing wort and instalialions performed under-the permit issued fortis appncation w7 be in - provision
Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. = ems/,�-_� /f ; -
PLUMBER-GASFITT ER NAME I ;, IY)'J r:rip. (UCENSE 1 I( Of - -- SIGNATURE
Nr liZi MGF 0 JP Q JGF 0 LPG!0 CORPORATION dit a FS 0 C. PARTNERSHIP D (LLG Dm 1
COMPANY NAME n'm'"
ICBwI &rr re. P____ - c. } Sd-4- ADDRESS!, �
1 I ,4,,i,j YIPGt 'h
- coy UJ. Yc./M/u- 1F% STATE 7 PI O2-675 ITEL a ric.i7 e,:.- - ti -
FA; )710-67851C81 s - _ . _I C. 0 0 k ' a e .t - III
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44:50-_(OD BUILDING DEPARTMF
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