HomeMy WebLinkAboutBLDG-17-003067 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
__t " CITY I '.�Lai_ ct t yi-!r .+'� MA DATE 1'�� I b (PERMIT# G-'17"' b0,A1(V
JOBSITE ADDRESS j 4
, J C,\ O(k v'n I OWNER'S NAME L •As 4 E C kV\.4-'1``
GOWNER ADDRESS " — TE FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
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CLEARLY NEW:Fl RENOVATION:0 REPLACEMENT:7.5A PLANS SUBMITTED: YES? NOD
APPLIANCES 1 FLOORS-. BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1 , —1 I . : ; - 5
BOOSTER _
CONVERSION BURNER ,, ,Mii
COOK STOVE 1
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Td!.11SR4:.. IRng ,1 244,apit
FURNACE
GENERATOR MOW j ,a,
GRILLE Aim i . _
LABORATORYNFREDHEATER COCKS M + � '
INFRARED ��
MAKEUP AIR UNIT MU _ ,.: Mir !
OVEN 4.1111111111 'P ! �'.�_.
ROOM/S•` .. 'III.'.. I . .
ROOF TOP UNIT ill*_ ;L 7____II, 1.[Mya _la _ :: _, 'tin,__,I
TEST WI ____ . I_________ ; - 1111FIA!imigt_____.: -- . ,,..______.' ____......_,[ .::____1,....:wil_. :0 - um
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WATER HEATER , _ MOM ._
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I have a current liability insu INSURANCE COVERAGE �-y�
rance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES l NO !�
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ell 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 n AGENT
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 co iance with II P rti nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 1/Q ffA �( LICENSE#7 IGNATURE✓ `MP Ul MGF Li JP LI JGF 0 LPG!0 CORPORATION 0#i PARTNERSHIP 0# _..i LLC Lj#=
COMPANY NAME: �l�yRl() { ADDRESS (
CITY ilS STATE ZIP au 3 TEL Vag- 3 Ks- 7S:c
FAX CELL. '_.. i Lathl(Dp C��IYI?�' �