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HomeMy WebLinkAboutLDG-20-005139 __ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rm ij e kr l j;` CITY :Ck . �1 : maA-�,_.._..,_--.._..,_.._,._I MA DATES (1 0901 PERMIT# bat,:- 'G' -er .5%f1 JOBSITE ADDRESS ci OWNERS NAME GOWNER ADDRESS Y1' r TEt 2-L 5 Z� -5 2 C .IFAX L.. J TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL© RESIDENTIAL ` CLEARLY NEW:0 RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES El NO f_ APPLIANCES FLOORS-' BSM 1 2 1 3 4 5 6 7 8 9 10 11 i2 13 14 BOILER - - BOOSTER 1` i .. 'f -T ��irt`— CONVERSION BURNER .f .r_ •: _- _ 'I_. ., IM �_,,. COOK STOVE __ __ — ,' >z t ���I -lam ...,_� , J DIRECT VENT HEATER ti i- �-I 1 all DRYER I . ..,-_ I I I FIREPLACE �= ? r i - ,. I - ,,..-, — FRYOLATOR _FURNACE ! C ._ 1 1 - - F GENERATOR ! ! ' -"- - " I 7_ Y1 GRILLE n�]M - ����;- INFRARED HEATER MI r- Iii IMM ._. _L I LABORATORY COCKS MI ;: -F - _I i _,m.,I 1 r I MAKEUP AIR UNiTMr 1' 1 T K~ OVEN 1. ' ..f( } i_�._._ .,. � . - - 1 POOL HEATER lint iiiiiiii i .- - ;i .. . ROOM/SPACE HEATER jj iI1j ROOF TOP UNIT �. TEST �m ,- _- �=- r r UNIT HEATER • 1 _' r.( I. =. 1ff 1 1._ .�...w.. . , __.I UNVENTED ROOM HEATER j 'W '51 - t .._ „: -111 WATER HEATE M I -x '_ r-. i - —_ l --U--._ . !�!1!Itl _ ._1 i OTHER ,�_...�._ :. I�_ ► k. I� ± .-•1 ._ .:. :_,.__. 4 -.... ._.- . Illl �llMi � l�lll�Il��l !!ll Ate. 1 I- : i _ 1 11 f 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 COVEY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY U BOND El 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 waive`;this requirement. CHECK ONE ONLY: OWNER (l AGENT 0 SIGNATURE OF OWNER OR AGENT i hereby certify that al!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. .? -,. - - �� l /%e6...v 1" - I- !7 PLUMBER-GASFITTER NAME j ( � _. LICENSE#cj,3.3 J SIGNATU MP( j MGF(l JP© JGF❑ LPG!El CORPORATION # 2;O Cj PARTNERSHIP 0#_ . ___.1 LLC®# COMPANY NAME: My-'5 PI01,.-,biht 1-wpc,(41--Mqs. I ADDRESS 1�45$'. 11 1Gi1,\:,_,$r, �,. _ ..... . . .. u.• _ . _ _ ______ CiTY 1104i 5 act ----- < STATE 11ZIP <_l__,A._ITELI Sc ;5 ` (6'1-11 FAX 5 c1 15.1 CELL___,_. JEMAIL EMAIL 14- .f.,- -C4,, pu flo .. _. -- _