HomeMy WebLinkAboutBLDG-23-9717 in endazi
��—,- MASSACH 1SETT"a UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS Fl TING WORK
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'�`-f�47 J� CITY '� � �� .� Cy i /.,.,
1 ' h�A DATE 3a 7? 3 PERMIT# )6— 1)._5 j,/7
JGBSITEADDRESS •Sf��Ng �--
GOWNER'S NAME� • °,r�,y ,�v��
OWNER ADDRESS/O C:..4 z2�' G4 �� 2 ��/� TEL '3YZ , 35 FAX
TYPE OR •
PRINTOCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
CLEARLY NEW:
RESIDENTIAL[�
MEW:❑ RENOVATION: ❑ REPLACEMENT: ❑
PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS-4 e5M 1
3 1 5 g 7 8 9 10
BOILER
BOOSTER I I 12 13 1
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR _ I ----
FURNACE
GENERATOR ----
GRILLEIIIIIIIIIIIIIIII
INFRARED HEATER M
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
—_
ROOM/SPACE HEATERMIMII
ROOF TOP UNIT
TEST ,
UNIT HEATER - . . .
UNVENTED ROOM HEATER11111.1111.11.11
WATER HEATER r
OTHER ��
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INSURANCE COVERAGE -
I have a current liat,ili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO ti
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ 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 Gc-ner s,and that my signature on this permit application waives this requirement.
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•', SIGNATURE OF OWNER OP,AGENT CHECK ONE ONLY: OWNER ❑ AGENT
4;; I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to
`'` and that all plumbing work and installations performed under the permit issued for this application will be in compliance ith all Pertinent
• Massachusetts State Plumbing Code and Chapter'142 of the General Laws. the best of my
`� knowledge
provision of the
PLUMBER-GASFITTER NAME 3M..i .30 jp %✓ —��__._
LICENSE ` ,, ,' SIGNATURE
MP ❑ MGF❑ JPy[�. JGF El LPGI ❑ CORPORATION ❑ff ci S _, 1
COMPANYNAME m pl^ava h PARTNERSHIP❑�r LLC❑it
��J,,�., "• • ��--__ ADDRESS
CITY ttle �jrY'�G�rJ_ }
STATE v" — ZIP CA.
FAX G`Y •..l CELL'''l / TEL�� •J y� J�
EMAIL=LJC 4J094"1 15 LvM L�i— Ai 42.7—