HomeMy WebLinkAboutBLDG-20-002684 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t'— CITY ILJ ittic t/(/rIA MA DATE] I PERMIT#hi--ar-Vp-45% ?Y
JOBSITE ADDRESS] 1441 C44,42 apex./ L in ;OWNER'S NAME ,f2 Q 0 �A 0
LI- OWNER ADDRESS I I TEL tFAXI
TYPE OR OCCUPANCY TYPE COMMERCIAL I f EDUCATIONAL L i RESIDENTIAL.(
PRINT
CLEARLY NEW:i I RENOVATION:I REPLACEMENT:+ PLANS SUBMITTED: YES; ; NOI
APPLIANCES 1 FLOORS-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1
BOILER 4 t I I 1
BOOSTER -- WI 1 • ,'Mil s
CONVERSION BURNER ; i
COOK STOVE ` ` I t
F-- - - YL.C.7 7 sae Ee ,,—;,' . a1_'�_
DIRECT VENT HEATER I i M I
DRYER u t
FIREPLACE t ��. .� ,-� � :: ..�0 � � �..�
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FRYOLATOR
FURNACE w 4- s .4
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GENERATOR 1
GRILLE r l } .Y I x
INFRARED HEATER . .< -
LABORATORY COCKS t- ,
MAKEUP AIR UNIT qq
OVEN i . - ��.�.1.`��.
POOL HEATER t .•_ =. t-,- - r. : •L.- -.--. . .t
ROOM/SPACE HEATER aaac• .�F ., 1414. T : -7 '
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ROOF TOP UNIT _ , ,•, wt.: att- < } r _ .4
TEST
UNIT HEATER
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UNVENTED ROOM HEATER + - t I '
WATER HEATER :
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OTHER _ ' y
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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 pi NO L1
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J( OTHER TYPE INDEMNITY ' ; BOND j
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 waives this requirement.
CHECK ONE ONLY: OWNER Li AGENT I g
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 Perti ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws
PLUMBER-GASFITTER NAME k C LICENSE#0 ,c(1,1,1 SI r -
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MP 'X i MGF! .J JP( I JGF I I LPG1[ I CORPORATION j I#4 I PARTNERSHIP i I#I I LLC I W#I I
COMPANY NAMED c.4ct.1M 0.„i, v.,1lti i bL1 T f2 ADDRESS�-('!_ C 12 t 1. • _ z 1 g1f�,kv Cc c,1--
CITY STATE ZIPi TEL J
FAX! CELL EMAIL •• `�
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