HomeMy WebLinkAboutBLDG-17-001148 MASSACHUSI=I I S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY !•Town of \ U I[I I MA DATE? /C2/JLJPERMrr# f��-,01'i7 7/1'
JOBSITEADDRESS! ,3 ar, _:OWNER'S NAME 1 f' ����
OWNER ADDRESS ( - �TEL Ni! .._..FAXt y
TYPE OR OCCUPANCY TYPE COMMERCIAL I i EDUCATIONAL 1 y RESIDEMIAL0 @
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CLEARLY NEW:7 RENOVATION:I f REPLACEMENT:Li PLANS SUBMITTED: YESLI NO _;
APPLIANCES 7 FLOORS-4 BSM 1 2 3 4 5 6 7 • 8 9 10 11 12 13 14
BOILER - 1 - ti' I
BOOSTER 73 _ i l i
CONVERSION BURNER ? 3 _�, ! li' -_ T J; r 'i
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COOK STOVE I_ a`_ :� k. 11 _ .
DIRECT-VENT HEATER i _11 _ ,I- _ . -- J AL —�DRYER I- +1 -�i i .1 _ - !_ i'
FIREPLACE __
FRYOLATOR I - ti_-__1= T .! !?-,1_-r. ( - �
FURNACE :)� €I - L A_ ,0L (L....1' 1 1!
• GENERATOR —11.1.111 . (^_-
GRILLE 1 ''. _ i - 1 f ._. 1 Tr • :
FR ._�
INARED HEA I ER I I .l .1_ ~-'
LABORATORY COCKS j- :, •' -. •' o
MAKEUP AIR UNIT 1.1,MilMiallitillil
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L_'�_ ..r7�il_-�i.,'
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OVA I 4i. 1' - - . „'
POOL HEAItt
ROOM
/SPACE HEATER _ _ _ , I " ; '
ROOF TOP UNIT - A - : n i a
TEST — f l
UNIT HEATER :, W` L _JL—'1 1 �� .T
UNVENTED ROOM HEAT ER Mom* L -- `_ _ °i _ -
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WATER HEATER - -. t 4__1_____.5_1_._ ._.i_
OTHER I '. ' 1 -
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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 NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY ui OTHER TYPE INDEMNITY D 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/ a best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comps'- - ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFI I I ER NAME u.; ir(-Br.AP __ -_ a LICENSE# I I-0011 - - - SIGNATURE
MP a MGF I JP LI JGF(D LPG( CORPORATION 1Z#ic3 8(,F G 1 PARTNERSHIP LI#� 1 L�-C D#�,_
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COMPANY NAMEi n�c.E rl ce PIu .4 r' c f, 1 ADDRESS 1 .11. n1�.'� --• p h
CITY W. `c.rir.:l Ld-f t‘ • 1 STATE MIZIP_ Qg 67.3 1T1=L 1_(56 k) 77 - ifia(2I -
FAY 6,a)7=10-6785I CEL! jEMAILI I(.M L -)! ,r,b.• i> cu!`,n.CC'.3-f- .6fi I
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