HomeMy WebLinkAboutBLDG-20-002751 of 117'
,' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
- J n
`�����6° CITY ,/' �m 6�t/� F'` MA DATE � /v C2-49l 9 PERMIT* 41-0G—X—Q'�.27S7
JOBSITE ADDRESS 53C ?L /OBI/ 0 OWNERS NAM060 AC
GOWNER ADDRESS TEL FA.X
NTYPE ��R
OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL izi
PRI
CLEARLY NEW:W. RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS—* BSM 1 2 3 1 5 6 7 9 10 11 12 13 14
BOILER
BOOSTER
—_i
- CONVERSION BURNER
COOK STOVE _
DIRECT VENT HEATER
DRYER
FIREPLACE I —T—
FRYOLATOR
FURNACE
GENERATOR.
GRILLE '
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN _
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
\._ _
OTHER
I
1 1 ►
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ,® NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY pi OTHER TYPE 114DEMNIT1' 0 BOND ❑
•
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1
Massachusetts General laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
s-i•. 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 •knowledge
`k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with a ' ent provision of the--
Massachusetts State Plumbing Code and Chapter.I42 of the General Laws. `"�-- - '"�'- —
4Z
PLUMBER-GASFITTER NAME7,C/i PO(t.12 l' LICENSE#5-/o4 SIGNATURE
MP ❑ MGF 0 JP 0 JGFirj LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME ADDRESS ( 7 L/f L P).,/?-
CITY fLyoz* STATE 44/ ,/� ZIP (7a?DC TEL TEL 8 - 6 y'S -c99° 3
FAX CELL EMAIL /./{0 .51F/ tVel-96 d23 Sifn7-Cr
�/r /7"
I
I
1
G2
A
['4
0
4
I
I PI
I A
ii '
1
i
1
I
...a
1 o ,�D
I of
1 c"1
2
ul 0
I C„) Lu
i A S L.'Pa., c4
t-- r
I ...".1I .. F uJ
cx
En
Q A.,
6,,, I—
Fiall L
[-w ❑—
[x.
CIO
lii
I- L
k
co
W
[°a
0
H
G
E-1 -X.\ ,
�4
U
co
V
I
I