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Home My WebLink AboutBLDG-18-005435 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK :,,I- CITYpc"t" \Ou'+. MA DATE 3 aw,/F PERMIT# Pb Jf'ae 6-ear JOBSITE ADDRESS Li 9 s f}S i de, talcire g_di OWNER'S NAME ,'.' "- A L.I G ' OWNER ADDRESS r- 4- TEI4 y/�j'_,3lO -/0.3 J FAX —+1 TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL,Z PRINT CLEARLY NEW:Z RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑ APPLIANCES 1 FLOORS BSM 1' 2 3 4 5 6 _ : 9 10 1. 13 14 BOILER ., I _: I BOOSTER r i I CONVERSION BURNER �. I �;1 i iliMil ill COOK STOVE I� I�I�---:� _' I DIRECT VENT HEATER 9 ? 1 ia' _______, DRYER i b �`— 7---1 FIREPLACE 1 1-- -1 3 I p -1.: FR I I I d ,I �I FURNACE F—plit—i I— I GENERATOR I `� j I 1 i GRILLE i I ,� r 1I i—-� I—�' INFRARED HEATER L i ' I I I I �;__E_� LABORATORY COCKS i � i W i, + MAKEUP AIR UNIT i _I_i I `I II F—_ ---��---�r OVEN i -- ; —aI�i 1 �_._-_r_ POOL HEATER i ,^I 1 I 1 Ins ROOM/SPACE HEATER i i ,i -1--- ' i ' 1---ROOF TOP UNIT L- - -� . __ . ' I ' - : _1- TEST ' d I; �� UNIT HEATER I ? i 1 p _! 'I 1^ - UNVENTED ROOM HEATER '_ 1 I �i 'I - WATER HEATER I i M , I I OTHER l iI i 1 - ►1 �11 — — — INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES,O n 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 General Laws,and that my signature on this permit application waives this requirement. _ CHECK ONE ONLY: OWNER ❑ AGENT ❑ - -- SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. G cell VitSe$04) PLUMBER-GASFITTER NAME, G 9q A, Vsa' LICENSE# 9d 43 / SIGNATURE MP❑ MGF❑ JP❑ JGF El LPG!❑ CORPORATION❑# PARTNERSHIP 0#I1 I LLC❑#I COMPANY NAME:I 6 ce7q ,A/Vci'^$o/s) IADDRESS y6/ )0A-(/4er I CITY I ()es-4- b 05-4->4 Lie I STATE I(na ,ZIP Ua 6 6 g TEL '7 7 y ?3 6 ?L5 a- FAX I I CELLI /i IEMAILI 3 rem Q/)�.Iei c-i (/)- D rnfl ) t,60 r't ait o T..�."< _ T_ ,,,�-®, M. - _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTIN WORK `"re fritAry CITY ) ccr\oo4\ MA DATE 3 a4,/ PERMIT#,Pb if-0a 6-9 s r JOBSITE ADDRESS L/9 s eiis'd e, Ui/4 g_dj OWNER'S NAME /,,i AL./ ____J tj - OWNER ADDRESS 4- TELI y/j' -,310-/O.?/ FAX —.] TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL❑ RESIDENTIAL, PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES , NO 1 APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 1, 13 14 BOILER BOOSTER ; 1,,,,, i CONVERSION BURNER € ' COOK STOVE I liii DIRECT VENT HEATER DRYER ii _ FIREPLACE i . pi .:, ; FRYOLATOR ..,._ , . i�_ FURNACE0 GENERATOR !111:1111111 GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ' 111111_____ 1 BM —' Ili NC-— OVEN . ,__ POOL HEATER ROOy1EATER . . ' - _ ..___ UNIT HEATER I UNVENTED ROOM HEATER111 M- � _ r— WATER HEATER OTHER ..I _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES V NO I €IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY ❑ BOND ri OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of ,he Massachusetts General Laws,and that my signature on this permit application waives this requirement. _ CHECK ONE ONLY: OWNER El ,GENT 0c SIGNATURE OF OWNER OR AGENT __ I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best o my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provi-ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. G ced 1 /� -(.56 PLUMBER-GASFITTER NAME I G -e A l ,SaA) I LICENSE# 4/d O3 / SIGNATURE MP❑ MGF❑ JP❑ JGF E.LPGI❑ CORPORATION❑# PARTNERSHIP❑#I I LLC #1 COMPANY NAME:I6<'.e9 Auc)-ee$Ot IADDRESSI 96/ p4(14-r CITY I U)&5-4- bit'1 5-M LI e I STATE I I ZIP 1 0? 6 6 I TEL I??y ?3 6 -II ..2- I FAX 1 I CELLI ' IEMAILI 3 fell o d ei'SOe) 4/01, 0 c(1-4 1 I+60 f•t 1