HomeMy WebLinkAboutBLDG-20-002961 MA ACHUSE 1 I S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
, " CITY ;Town of Y,4 (Y)p( tea— _ } MA DATE? 'i r% PERMIT#tADb ad- ,Q4,1
• JOBSITEADDRESS! A7 UrrliataLrP1y Yam,1OWNER'S NAME I Vr*c 111aL,I ton ;
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kir OWNER ADDRESS j 1 I (4),X.)77- ivr IFAXI
TYPE-OR OCCUPANCY TYPE COMMERCIAL
PRINTFrU IGATIONAL El_. RESIDENTIAL
CLEARLY NEW:j 1 RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YESLI NOS
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APPLIANCES 1- FLOORS-+ BSM 1 2 3 4 I 5 6 7 • 8 9 1D 11 12 13 14
BOILER - t <__ - L-__I 0 — -,_.,. r i--
BOOS I Eli
DIRECT VENTHEATER F Mil _:-
DRYER —I MME M M__
FIREPLACE Imo ; _ :
FRYOLATOR !-__ @ r ;
FURNACE -- -' '_ - — - isoriscimmit
GENERATOR .: , ;
GRILLE _r._ -�.i '_._ Tft:i ` , `'S'.r1_
INFRARED HEA►EK am, i '� m
LABORATORY COCKS '' ' • r' • • •- " /
MAKEUP AIR UNIT �i �f1[�h.[.=�:pj��j ���'��� y
OVEN :��, . . lijiZ;='r'�:'�j ' 1 c! ,. tr -_
POOL HEATER S 'ti -�� ]1.�,1.. :,...•_
ial
ROOM/SPACE HEATER 1' ,l''_ _ = Ida �.,� ��:
ROOF TOP UNIT ' +� � ' -1 ,.�,�1��i
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UNIT HEATER - ( MEI
UNVENTED ROOM HEATER - _ .4 _ Wm. . r._ m 'mia))>C
-WA I Eli HEM ER - - -limit
OTHER ! _
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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 Eti110 ii
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW $` 1 `
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LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY D - BOND U
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OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required byy'Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement / , [' j
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• CHECK ONE LY. 0 ER D AGENT f 1
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this appliiceton are true and acarrate to the best of my knowledge
and that all plumbing work and installations performed underthe permit issued for this application will be in compliance 11 A,�, provision of the
Massachusetts State Plumbing Code and Chapter 142 rite General taws.
PLUMBER-GASFITTER NAME pv�r "c c. p _-f I LICENSE# 7{ - S0, - SIGNATURE
MP a MGF D JP 0 JGF D LPGI U CORPORATION Eg#Ia FS 68 G 4 PARTNERSHIP DM 1 LLC DA E
COMPANY NAME �er�n- c-BrI c aRim-- ec=L Z7c, ADDRESS II 1 rnncJpSP Di-A I
• Cm' W. `c,,-rnc)r✓ft, . 1 STATE M ZIP ,0 C��73 !TEL /56kS - 55 1 -
FAY6.a£1710-67851 CELL.So s 3 4r?7v EMAIL' k(Y)G p)U^-.^ L c_"-C)r"f,c L,4 , r;(-L.- I