HomeMy WebLinkAboutBLDG-19-000131 I`71 C_ p I` c_A \- C
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY —1j(jfill/.v MA DATE PERMIT# 6""ft-aAV;j
JOBSITE ADDRESS y /. /'1.G .. '/Cp t(. __ OWNER'S NAME //diet/
GOWNER ADDRESS I TES 1FAxi
TYPE TR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL L RESIDENTIAL,
CLEARLY NEW:Li RENOVATION:(1 REPLACEMENT PLANS SUBMITTED: YES® NO(0,
APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _.. __.. ._ +.._ ..... .,......„._ # _ 7�
BOOSTER . I____ '! _ _"_._1_.__1 ._ f_3.,_,___i___�. ..__.a_,
CONVERSION BURNER : _ :( .__. j ?L :{_�_.�#
COOK STOVE
DIRECTVENTHEATER - ______ }__ i i__._.__=f :i�_ i €_ .__I____,1 m ___.__1____-.,
DRYER1____;I,.__._-- __.__-�i___.__ ... _._ .__ ...L_.... . #_.....__1__._11__ .--,.1.__w
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FIREPLACE I `I 3__
FRYOLATOR 1..,, __.... 1 l _,....=I . _ ...._._
FURNACE i
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GENERATOR --
GRILLE i I ' .. ... 1._ ,._.,: ._ . I. , ' '' _I .... Al
INFRARED HEATER .:'_ _1 '• _
LABORATORY COCKS _MAKEUP AIR UNIT = I
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OVEN i —
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POOL HEATER _ _ 1_.__.__°!
ROOM I SPACE HEATER .'I ... 1..� _ ; ... . ,�_
ROOF TOP UNIT +. ._ _ ''. ..... I:...__ .._: ._.._ i I I ...,....__L. 'I if _IL, 11_
TEST I_..._.,. ._. ' i€ E^ ,
UNIT HEATER 1.....�z 1 I ,:i.,. . : l f— �
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UNVENTED ROOM HEATER ` 1..: I-x: I I i I _.. ' 1 1 11
WATER HEATER - 1... .._; 'I 1,
OTHER I I '1 i:_ I `I_:... --_ _:. .. .. 1_::. 6---7, 1 1
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1 41 1 " ,lI_ !I
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INSURANCE COVERAGE
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I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 12,,NO Lj
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 12g,s. OTHER TYPE INDEMNITY lD. -..�- BOND L
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
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 complia ith all Pt provi ' he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME C c,r I S . P,; e d e 1 l ' LICENSE#-8 G i S ATURE
MP 0 MGF 0 JP® JGF J LPGI 0 CORPORATION # 1 PARTNERSHIP(`# LLC j #
COMPANY NAME:,..0 c,r.J._.._F... .._h,- ed.e L_L..._t _5.0..n A ADDRESS l_-7_7.. .. .__..._.i _ _.!!-,.v......._._S_!.._ree _._.._.CITY O s t-e r v 1 Ile I STATE M A 'ZIP _U a.G_5 5_.TEL ....._5 U�'s_" yD. - - .0 .__I3 5...._..,
FAX .__._�_. ...._: CELLS EMAIL
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