HomeMy WebLinkAboutBLDG-17-001602 /O7/9/31 /C3IRC -/
MASSACHUSI i I S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY !Town of y r`stDU a MA DATE? 4 PERMIT /7'OO/e!O2
- JOBSITEADDRESSI /// rafiz,7,/t7 -Sit//PA _ OWNER'S NAME ? k '// i,..4.t/7 J
•
OWNER ADDRESS ( - . 1 TEL ___ �� FAX! 1
TYPE OR OCCUPANCY TYPE COMMERCIAL':i Fn11CATIONAL i j RESIDENTIAL EJ
PRINT
CLEARLY NEW:i_ RENOVATION:1 i REPLACEMENT:Li PLANS SUBMITTED: YES NO Li
APPLIANCES 7. FLOORS-+ BSM 1 2 3 4 1 5 6 7 8 9 10 11 12 13 14
BOILER - $ F-_--..O i _.:
BOOSTER ,_ ,
CONVERSION BURNER . it ' _1i- — •
COOK STOVE MU ' 1 .
DIRECT VENT HEATER MIIIMI, -_ -' ' - '---1_ 1.—_-:Iillir - _
DRYER ,I •;--3 ! _ 7'
FIREPLACE Mil, I _ 1 -, — _ _. _- aI _ .. 1-_.
FRYOLATOR I - ''_— '—,._ _iL — _ I !� � .--1---.__. I—.- -.�,.._.� _ -.
FURNACE NMI __ •I __ : -- + _ � —.#hi.,
- GENERATOR __ 1' - - 'l -
GRILLE ..V__ - tL _ - L_,..e_ t_ NA rES ANI :_ T.
INFRARED HEA I EH MOM' -- ' ' _ �1,, ,'G,�_„ ' am i -1._
LABORATORY COCKS - v__ c _ . ir! _
MAKEUP AIR UNIT am, t >a1iL*t1W ' _ i .. • _
OVEN
POOL HEA I ER ' m` _ , _ S + ti,a ak.. .
ROOM/SPACE HEATER ME' _ ' _ _ i mom ` '
ROOF TOP UNIT - 11.1111____ _ 1 _ I--- .._I1-le• } VAI4 !ii�.,
TEST . i _
UNIT HEATER imilimi, -
UNVENTED ROOM HEATER __ : _ _ v=1 '. __
WA I ER HEATER
011-1ER I _ - _ - -_ 1'_.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES []NO LI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY JO OTHER TYPE INDEMNITY D BOND ill
OWNERS 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 0 AGENT ri
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 lh a best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this appk-alion will be in compere with all El•wilwit provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - -
p,U P -
PLUMBER-GASFI I I ER NAME , �. P b LICENSE# I Imo?O: - - -_- SIGNATURE
MP a MGF 0 JP 0 JGF 0 LPG!Li CORPORATION #is 8 4,F C. 1 PARTNERSHIP ptii /I LC D#L
COMPANY NAME:l6Nn I r r('Sr=C)e PIuA±-§ H ac-t . ../)ci ADDRESS 1
CITY W. `/c,Er`- -F I - 1 STATE ZIP C._673 1TEL 1 (56k) 4 5 _6, 3 .
FAXSo`r)710-43.785 I CFI I {FirukiLl I
• - • LR )--1
CD
�� , _-, ,