HomeMy WebLinkAboutBLDG-18-003408 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'jig= CITY \ C Z \Qt.„..)� MA DATE wr_v _„„„,1 PERMIT#PAPir lr O
JOBSITEADDRESS; _\LL__UD c .�C�.� OWNER'S NAME , ,, �C.
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OWNER ADDRESS I .. TEL FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Li RESIDENTIAL,
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:1 PLANS SUBMITTED: YES 0 NOE]
APPLIANCES 7 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILERE � �(
BOOSTER _I LEI. .,.--��. jE ! 1 1
CONVERSION BURNER ( 1, 1�
COOK STOVE ( ._.., 1 :4 I ,_ . _
DIRECT VENT HEATER :1 1
---
DRYER 1 i;_ 11
FIREPLACE
FRYOLATOni
E
FURNACE �I 1 E � 1 �.> _ . _.
GENERATOR i"` i ---' 1 _ E_--_ e 1
GRILLE H1 II" I I i ,_ _ �1 _ f4
INFRARED HEATER 1 II ,_.. . _. ..:.:._.'I.. .. ;I E I 1 E 1
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN 1
POOL HEATER AIM...
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER I = __ :7_1I.m I _. 1 t.
UNVENTED ROOM HEATER r IL , i I_ -12 i
WATER HEATER
OTHER �
I1 .!,- I 3E II ( E e I E, d1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ZI NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ta OTHER TYPE INDEMNITY '--j BOND [
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 L<
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 Pe t provi ' he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ `�� Q��
PLUMBER-GASFITTER NAME C G,r-_I_ _ 5 e de. 1I j LICENSE# .- y(s S1GKATURE
MP �� MGF JP Ej JGF El LPG'U CORPORATION 0#1 PARTNERSHIPD# 1 LLC D#L ...,.
COMPANY NAME:.C c r I „1 _ ._hi_E.c d e_I I r _.SG n ADDRESS 17 7 . i�I,c,!n 5 c re 2. t
CITY US t e r-v E lie STATE MA;ZIP . U a G 5 TEL 5G.S y _ss ...C.3�C._5_ ,_
FAX tl. CELLS.._. _ _EMAIL?......
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