HomeMy WebLinkAboutBLDP-23-11888 (2) _ /ri rtr R ' -.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`i.m�I" y¢ CITY 1 W( . ICL(r • _ I MA DATE` S1,�-; I PERMIT# 83/ ,IY' 2 3. `/SY,.3
JOBSIITE ADDRESS cL .lc�� x :_ ��� !OWNER'S NAME ��{c -C C-aC�: %—�— . r. 1
GOWNER ADDRESS C. . ,..�.�, . ...,_ Ttr`f.m�� .. ,.._, j FAx �. ---jj
TYPE OR OCCUPANCY TYPE COMMERCIAL L] EDUCATIONAL fI RESIDENTIAL L.J
PRINT
CLEARLY NEW.® RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES I,1 NO)
APPLIANCES I FLOORS-, asM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER WNW
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BOOSTER ag , C .CONVERSION BURNER f; '�.. -COOK STOVE M grm
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DIRECT VENT HEATER ON I fI1 '1 I
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DRYER -..: .0fI
FIREPLACE t .1110110114 . i a11.100. i _
FRYOLATOR .i1 1 'f !f ': i—'fl'
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FURNACE
GRMOKIIIIIIIIIIIIN
GEILLE
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INFRARED HEATER i i :se r
LABORATORY COCKS _ I. i otzwom
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OVEN 'f I- ° Ii _ I-
MAKEUP AIR UNIT i
POOL HEATER IONIIIMINImitipopoiiiimisiiiirnimisioutomusaii
ROOM/SPACE HEATER !�� wpm: I00110111 v .:1I _j.
ROOF TOP UNIT �;- ....., I... .-..' it _ - �, lA -.
UNIT HEATER r-xf - ' '0
TEST.i �I,t liL •
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'INVENTED ROOM HEATER !; M L_,.,; i i > I L wJ r
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WATER HEATER .., .,. i ' i1111111.111 fs
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OTHERi i \Pr*CeltaktOr I �� 11 f 0'41 MIII !_
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1 NO Li
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ee OTHER TYPE INDEMNITY [J,j BOND f,.I
OWNER'S INSURANCE WAIVER:I am aware that the licensee dges 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 Li AGENT El
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. & Z
PLUMBER-GASFITTER NAME f 4 A _ r I- G I V LICENSE# ��. ! SIGNATT E /
MP at MGF Li JP 0 JGF 0 LPG'LI CORPORATION J#� G PARTNERSHIP[D#[ —1 LW f J#( _J
COMPANY NAME: ,3G. fl,4„,,►-Zc..v�.. 4-- 1/ —Ii1te&I-ADDRESS!,in '7"y .;:, .... _ .__. ,_
CITY ,,,, 42.& ,c J? I STATE f./in.ZIP[LG<3 az ]TEL o d'g7 3$tl L
FAX - q b fSi CELL[ , JEMAILLELlc„L , ,,,,,LG.. I.,t n xii,2 rY. „,...A2 .,”L„,_