HomeMy WebLinkAboutBLDG-20-004464 #16B PAA-P: P4RC&L-
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
n'.>1 .;. CITY ( � '^ 4')1 cti t,'` ,•,. MA DATE `a-G 'aC2)( PERMIT#/ "`, - `/4/ Y
JOBSITEADDRESS(I�n L'� t'•'ra r�i�r (I;� __.._J OWNER'S NAME L ' rvlc a0rim4E " _„:--:t
GOWNER ADDRESS f Ul, j I =�rv� -�TEII.S'7,210,Z1 i0 S IFAx1_..-__ __._-.-__I
TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL 0 RESIDENTIAL 0--
PRINT
CLEARLY NEW:0 RENOVATION:U REPLACEMENT:0 PLANS SUBMITTED: YESLj NO3
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER AM _. .. i Iu . _ ._ , `
BOOSTER � i i l _ i III I �__ 1
CONVERSION BURNER i' I� INr� _ I 1 ! iI I
COOK STOVE PVC._--- V 1r _ — - ---- -- - - -- - -
DIRECT VENT HEATER {f•y is `t i
DRYER - i ,_..m . _-1, __ 1� _ Imo_ -
FIREPLACE
FRYOLATOR - �
'�' it, a ,-I I
FURNACE ]$1I ill l l l 1 l llip-' _ill
GENERATOR -11.10-111.01,1-01-41MIRMUM101.1111110110-10-1111-101011611
GRILLE 11.1MtliiiIMOMMINIIMINMO111.1.01.11-7M110111
INFRARED HEATER -i r �i j II � o u
- __� _
'LABORATORY COCKS - t ni � j __
MAKEUP AIR � �r "�
OVEN _
POOL HEATER . ' ' I -
1
ROOM/SPACE HEATER cinni i i I ' II I
ROOF TOP UNIT ] i1 I:_r,r- . l: ,_li o f i ]iI I;I ` ii-_-
TEST i -f 9 _f._,,,,,..I _..Ir_-..-_ _._.... _ .,
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UNIT HEATER - „.,I . ...I.:. 1 i „r.�..lr�_ I f
UNVENTED ROOM HEATER if i ,. I .. IiM.__,_
WATER HEATER _
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OTHER .. -- I _ iI 4
I) MP um. E I ill i mwmgrogn
INSURANCE COVERAG
I have a current l€ability insurance policy or its substantial equivalent which meets the requirements of MGL.Chr 142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA :Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY INI OTHER TYPE INDEMNITY Li BOND Li
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 0
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 pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ? `"
PLUMBER•GASFITTER NAME `� c �C' �c'' _-/ „• �,
r216L I'1_,L fir,-, '.z, ...—. LICENSE# ¶3 3'(� - SIGNATURE
MP[Z] MGF 0 JP 0 JGF® LPGI® CORPORATION 53#(3QL' o L I PARTNERSHIP[. #+_ __ LLC®#1—
COMPANY NAME. .1 ' I bi` , y J ADDRESS ih.,2__-__.. , _____ n
CITY i STATE tali ZIP U9{0 a Cj ITEL .7i Sc . 1 1-1
FAX .Sg - c1 k�ciCELL „t__ EMAIL LC:-?;r,,2_(�;, pLt. t
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