HomeMy WebLinkAboutBLDG-17-00103 /71 A/° /J9/P c e.,/
I MASSACHUSE I I S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY ;Town of YAW;0 u 1 /I I MA DATE!p :2 i L-; !PERMIT# /PL/•0&/7 6,u,i
JOBSf IEADDRESS! / 41 el. gri—I' Q9 `OWNER'S NAME l 1Ir•, I/ _( ,/� -
kir OWNER ADDRESS ( "-'>I S0;.,)444,. 7,):a I F1 _4
TYPE OR OCCUPANCY TYPE COMMERCIAL;ial EDUCATIONAL E °=3
RESIDENTIAL
PRINT
CLEARLY
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NEW: RENOVATION:+i REPLACEMENT:ET PLANS SUBMITTED: YES NO LA
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER - I $ t k e P f . .—.-. Ii 4_
BOOSTER 3 _ L_ _ i _ ki f' f__—j 4. __ ._ .
CONVERSION BURNER ! , ,�a i _-•,� t !L JL
COOK STOVE a�_ i1
DIRECT VENT HEATER b 'L +1 __ I t t: s _ _MI _I
DRYER {: il_ , ,!i - i, -— 1—_41 1__-=- __-Ji ___I.--- _, . ' O.FIREPLACE i —11______) 71 __ _ J! _ - :- �-- __ � . , Lw _..__It_ .
FRYOLATOR I._.___t ;; _i 1...- L s. 1,
FURNACE Mt '• ' - - _i_t_ . i ! i= 1
GENERATOR _' e_ — - _ • ' -:.__gl__ J
GRILLE MIIIIIIIIIIV . _' _� ! ____1_ - - 11-7 ______
INFRARED HEA'EH ` 1 : •, ---. `I ,__. __ I _ _
LABORATORY COCKS _w ._ '' ' jiL1'L- `,?1; `' - t. • m 0
MAKEUP AIR UNIT • . _— • I _ '"_ t. _ _ j,aii _ p .
50 � C h10 in
miiii�.•I i�r�1�1 f, N
POOL HEA 1 LK ' 1467 ' i�lli' '{ k iLt' !'1L�;
ROOM/SPACE HEATER ;,�,,; - _ ., _ _ , ,p �A t ` __�.
ROOF TDP UNIT • �'__--_1 - _' - 1'r-" Kq W !' I
TEST _ _- P
UNIT HEATER k • i_ i - ! ._____J
UNVENTED ROOM HEATER ',..........4 __ _. r ' f 'I ':- I — -- -1
WA ER HEATER . _ _A_ -___i_t !.- - . •--. i _ ___
OTHER I
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INSURANCE COVERAGE • 1---�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES t°NO Ill
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCYC47 OTHER TYPE INDEMNITY D 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 D 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 ' a best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn n =n D-. ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFI 1 I ER NAME k r, f CB r.Je LICENSE itI I b O a - SIGNATURE
MP 0 MGF 0 JP Li JGF rj, LPG!Li CORPORATION iZ#I c3 8(, 'G 1 PARTNERSHIP LLC J#F—
COMPANY NAME r,.mc`&i&;c-L PIo Net 4 u-} S-nc gI ADDRESS 11
, DA i
CITY . W. `e.rer.:)c.-ftti • i STATE IMZIP Q, 673 ITELI (5a42) ?7g- 4 56 ; •
FA4So1•)7=t0-6'7851 CELL 'EMAIL!
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