HomeMy WebLinkAboutBLDG-23-9408 #-- /A)/ - 5-2.3 R__
` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFOR GAS FITTING WORK
i.-_ L�..c,. CITY °ter w.c7 v�k-••�vC's } MA DATE c.I l�3
�' '' PERMIT# L% ;
JOBSITE ADDRESS t 0 o o`A.4,4--4 r�0 c). _ OWNERS NAME Sco4-4 Mc_ C. (e-kkei.
OWNER ADDRESS I o o 4-cc...31-1.4._✓'t..-t)0 cl TE(.5b15) SG 7 ' `(779 FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL 6�f EDUCATIONAL ❑ RESIDENTIAL
CLEARLY
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NEW:❑ RENOVATIONS REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES I FLOORS-- MIA 1 2 3 1 5 6 7 9 11 12
BOILER 13 1
BOOSTER --
CONVERSION BURNER
COOK STOVE —_,
DIRECT VENT HEATER
DRYER
FIREPLACE -- I
FRYOLATOR
FURNACE --
GENERATOR
R_ EC EI '
GRILLE y-� y
INFRARED HEATER �� I ^J
LABORATORY COCKS '� --�
Au�' 2�2�
MAKEUP AIR UNIT __.
OVEN Oity ucFT�d
POOL HEATER -- By �L I 1—,
ROOM/SPACE HEATER —❑--=
ROOF TOP UNIT — '
UNIT HEATER - - -• _....
UNVENTED ROOM HEATER
WATER HEATER
OTHER - c-:X C,wS lco-\cS oh I. t
INSURANCE
I have a current Iiabili insurance policy or its substantial equivalent which COVERAGE mets the requirements of MGL.Ch.142 YES [S-°
0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY EKv OTHER TYPE INDEMNITY ❑ 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 valves this requirement.
•
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER IDAGENT El
!I-, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc ate to the best of ;nowledge
,..,`!il,— and that all plumbing work and installations performed under the permit issued for this application will be in complian . ' all Pertinent €si n of the
Massachusetts State Plumbing Code and Chapter•142 of the General Laws.
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PLUMBER-G 'FITTER NAME 1( (1.�. Q . S-v- .
LICE JSE ` (S Zg( SIGNATURE
MP I MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION IMF % I� PARTNERSHIP i
�(o RTIV�.RSHIP❑�� LLC❑11:
COMPANY NAME t�S (/ly Ae.k-3.,- ��. \ �L_ ADDRESS L{ iiCA 4t).-:•\ \1"—
CITY ./t✓ STATE Mc ZIP a_3)()
FAX CELL?711-an- Z 1 I`/ EMAIL IceS t' ( 1T ekr..t) cL4-''i i 7...0