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HomeMy WebLinkAboutBLDG-23-008784 lid--------: `�=`� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT �'. . a CITY T Cl P ERFOilVI GAS FITTING WORK RK °� Imo, DATE JOSSITE ADDRESS 1` ` -j e n V j ✓ PERMIT# L 06-�3- 8 7 9 OWNER'S NAME ekL G GVUNER ADDRESS TYPE OR TEL C" FAX PRINT OCCUPANCY TYPE COMMERCIAL CLEARLY ,�� 0 EDUCATIONAL 0 RESIDENTIAL 0/— NEW: RENOVATION: 0 REPLACEMENT:0 APPLIANCES PLANS SUBMITTED: YES 0 NO BOILER FLOORS-. �00®�©©0 BOOSTER inalrawaralnari ®=�®® 1; f CONVERSIOIV BURNER - COGK STOVE �-- --C DIRECT VENT HEATER -�-- �---5- -M-- DRYER nrunwmmmll.M.II.......mm,..._IMMIMIII.M.MIMIMIIINMIMM ---_-=—=-- FIREPLACE - FP,YGLATOR - - - GENERATOR nriamilimrlaraINFR HEATERC ��- LABORATORY COCKS1111 ��-- hGAKEUP AIR UNIT —_ ��-- OVEN __ �--- POOLHEATER —� �� ROOM/SPACE HEATER —_ �_ ROOF TOP UNIT —_ _—�-- UNIT HEATER ®® ��_ UNVENTED ROOM HEATER =_ ���......®����...,,,� WATER HEATER �© � w OTHER _- t'3^�_ �C iir_�� I have a currentliahili insurance policy or its substantialINSURANCE COVERAGE • -- I IF YOU CHECKED YE5,PLEA6E INDICATE THE TYPE OF CQVERAG BY CHECKINGwh�hmeets the requirements of MGL�Ch.142 YES R!0 ❑ THE APPROPRIATE BOX BELOW LlABIUTY INSURANCE POLICY OTHER TYPE OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insuraInce coverage❑ BOND ❑age required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement.ernettk `.? •� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER �� i hereby certify that all of the details and information I have submitted or entered regarding0 AGENT ❑ "s and that all plumbing work and installations performed under the permit issued for this application will he i ,� Massachusetts State Plumbing this application are true and accurate to the best of Code and Chapter 142 of the General Laws. n°p • th a P ine y It wledge PLUMBER-GASFITTER NAME r vi n fthe LICENSE4 r MP 1 r,AGF❑ JP❑ JGF❑ LPGI # L '07 SIGNATURE �` ❑ CORPORATION[ Gf ' PARTNERSHIP❑ COMPANY NAME LLC❑ e ADDRESS CITY STATE � r FAX ZIP CELL — TEL ` %- � `! EMAIL _ .1 �` L A /