HomeMy WebLinkAboutBLDG-20-005157 !,.\k0 •- ....
, ...;._.. MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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riTY C \tit Vvvit usiv1 i MA DATE'3113\ao j PERMF# "1-041',A0-CV6731- N"
JOB.SITE ACORESSI Vgti .to C•-vill)laid 1)V..., 'OWNER'S NAME ',..leSiS, CS Lie L.-1-C
OWNER ADDRESS 1, il(0)cltS - 1g 48..4( iFAX
-i-YPE OR OCCUPANCY ,----,i
CUPANCY TYPE COMMERCIAL 4 EDUCATIONAL RESIDENTIAL X
PRECT —
CLEARLY NEW: V.,... R:7NOVATION:1--- REPLACEMENT:77 PLANS SUBMITTED: YES 7- NO7
APPUANCES 1 FLOORS-
BOLER ---lt:--1--1 i— --1. 1111111111111111111111111.:
BOOSTER i ...' Mi-
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CONVERSION BURNER . ,
COOK STOVE i •watilllir _______ 1 . _ _ •'.• _ , --,_:_-__.,..-- .- ----- --• ' ---• DIRECT VENT HEATER i MS dig 1111111 /10'
DRYER . nit OM' 1 gell ow ,
FW...PLACE L, . Nail ir i j, i NM alit
FRYOLATOR I _ 11111111 _ . . .._ alp illillEMIlf,
FURNACE 17, II VIII MIK 111111111111111MIMP • .
GENERATOR SIMI aim iiim 1.10111111111111 EMI Ma 111Ni Ilimit NM 111111#11111 .
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INFRAW.1)HEATER M__ ,
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POOL HEATER ' iiiiiiiii Niii milismoir mialatilUlliffillialliu
ROOM i SPACE HEATER
111 1111 III III 1111.Win!IIII
TEST IIII 111
ROOF TOP
' ' 011.1 aili ilia ini UMW iintiM iiir MN 111.111.111 ille MIME
UNIT Kr:Ai tH I -..-- MIII ,ONVENTED ROOM HEATER ._ . . . _. .. ....,_
WATER HEATER '7 MUM aim _im, . ._ motingion on
,. oTHER ' allikipm. Ili alliminueliami illikaistlim IMIL,_____,,_,_
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- - . --- -- -- INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch..142 YES .:k NO
CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEI ow
umattsrY INSURANCE POLICY 1(_ arrIER TYPE INDEMNITY 7 SONC
YNNERS INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requited by Chapter 142 of the
Ma.. .,ai-..husetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER AGENT
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SIGNATURE OF OWNER OR AGENT
hereby =1.t1f'y tw ail ce the details and information I have submitted or entered regarding this appikxition are true and accurate to the best of my knowtecce and that all pkimbir.:,..;work and in...ailations performed under me permit issued for this application will be in oarapiiance with ail Pertinent provision of the
Massacnuset's State Plumbing Code and Chapter 142 of the General Laws.
Y%-... 77.:2;r3e" ,.."-•••••.
FLUMI3ER-GASFITTER NAME____________________ LICENSE#i:112 SIGNATURE
MP i.V,,i MGF----__...,i JP'-7 JGF,_. i LPG r CORPORATION k4i#',a:2)4,6 Ci PARTNERSHIP Ijiti .._ _i I.I.0—14
riTv .,,. T _.,.. ...: ,.. ....„.4)..444::Lz., i STATE /kk ZIP: c2k-Go ....!TEL
FAX 7.1_7---irli.. .1 CELL
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