HomeMy WebLinkAboutBLDG-16-003589 ._ MASSACHUSE I I S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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. CITY ;Town of %4v�j p//t 4 MA DATE!"s tr//S' 1 PERMIT#,b'/6-C1,,6W
JOBSITEADDRESS!it F1-, ,- :r R /- Cr 2 ?OWNER'S NAME 1/704,i( G,//��'‘,',-i-Y1-7
OWNER ADDRESS I - 1 -__ —__.__�A__ !FAX i
TYPE OR OCCUPANCY TYPE COMMERCIAL i I EDUCATIONAL Cii RESIDENTIAL
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CLEARLY NEW:'i RENOVATION:' REPLACEMENT:Li PLANS SUBMITTED: YES 0 NO
APPLIANCES I- FLOORS-4 BSM 1 2 3 4 5 6 7 • 8 9 10 11 12 13 14
BOILER - ? '!
BOOSTER MMI1 _ , _ . , _ j ; _ p! —.._.
CONVERSION BURNER Yi i' I _ 1
�:� _.;��.--mot_ � �i _ .� �'L__
COOK STOVE _1_.--! -_ f 1 _. - _ ...
DIRECT VENT HEATER �' i ; I _P �I^ q
DRYER ' 1_ & + J _ I • " i___ — —41. -
FIREPLACE 1__ R.__ _ -' Lam_. : __ — _ __ _I !.--
FRYOLATOR _ I 1 _, 1- -
FURNACE fir MEI._ -- ' _ -'. 1 -=1 L 1=L_,..__
- GENERATOR ` ____ 1 i _ '
GRILLE : ;i -i r, _ -
INFRARED HEA I EH - _ + - '•_____-.0*- r . _ L....LI- -L • t _
LABORATORY COCKS I • '' - • o t
MAKEUP AIR UNIT Mt - ;' - MUM `' _�1 :zh� r1'r.I1Li.'.jLlii' . ..
OVEN ••: i;a r m ..i. .. 1.= _
.POOL HEATER
ROOM/SPACE HEATER _ _ I y M :.:. L._A i
ROOF TOP UNIT - ' ' ' _ _ 1 ! is 1
TEST ! -
UNIT HEATER NM, _ i._,_,_ I I I ,
UNVENTED ROOM HEATER ___i� L '' '.. 1 _ __J!J; I J
WA ER -EATER 4 - -_..._ 7 ...__J_1t . _I __ $
OTHER -' _.J' __ ' `- 1 11 I _°
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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 0 NO !l
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY D • BOND CI
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 0 AGENT f E
SIGNATURE OF OWNER OR AGENT -
I hereby cerfify that all of the details and information I have submitted or entered regarding this applica5on 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 comp all 0. rent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - -
PLUMBER-GASFI I I ER NAME,kev;n fr CB r.jP , s LICENSE# 1(__� t_O - ` - - SIGNATURE
MP b.d MGFLi JP I__ JGFU LPG LI CORPORATION 61c38‘„SC, 1PARTNERSHIP Offi 1LLC0# i
COMPANY NAME n_Mc.(JrI c)e. PloAn-f }- .ac y cJ ADDRESS
CITY W. `r,rrc,),,-}'1,, - STATE MZIP, 4�-673 1TEL) 5 6 ) ?7g' 4 5-5- i -
FAOa)7'-tc?-h7k5I CELL !EMAIL! E
- - - •- /C• 71.:.-. 4 qo tie '
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