HomeMy WebLinkAboutBLDG-19-003247 Sow
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_v,.— ft o
CITY t I..a_y tf _ . ! MA DATE: PERMIT#/46-- -C40 Orr
1 JOBSITE ADDRESS:i/I OWNER'S NAME . +_-r_- ._..._..
GT OWNER ADDRESS I TEi! j6" c/ i ( FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL L
PRINT RESIDENTIAL
CLEARLY NEW:~ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES i. .{ NOD
APPLIANCES Z FLOORS-+ BSM 1 2 T 3 4 5 6 7 8 9 10 11 12 13 14
BOILER ` —'—
BOOSTER III �
l
CONVERSION BURNER j „ y I ;) I r L
COOK STOVE 1� ? �- 1_._ i -,1
DIRECT VENT HEATER --_�'I -{^ r ! r
DRYER 4
FIREPLACE 1
FRYOLATOR L_... f __ rawar m_w .� i 1 ��_, _ , _.._ _ ___ ._. .__, {
FURNACE r
GENERATOR 4:
t
i ,
GRILLE ?
_..-_._ { l I .... 1�rosy I � ........................
INFRARED HEATER { y �_.
LABORATORY COCKS C i --- 6- - - ,---',
MAKEUP AIR UNIT
OVEN 1 l
POOL HEATER t _.. l� y ; .. ._
ROOM/SPACE HEATER _ r L-# I _ .' _ 1- .._.. ,a _.. ..... -
ROOF TOP UNIT ,. .'i i i y
TEST - __ ____'1....._.... ,..,., ._ :. - _ ,_ '1.m
UNIT HEATERIC7-^3., I
UNVENTED ROOM HEATER '{ 1, k j
WATER HEATER T ± ,—n '
OTHER 1 L
tl
y :.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ''f NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1.W..:1 OTHER TYPE INDEMNITY ;? BOND
OWNER'S INSURANCE WAIVER:lam 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 AGENT U
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Cea-)
PLUMBER-GASFITTER NAME'Crai Bisho LICENSE#15101 !j J SIGNATURE
MP MGFLJ JP ll I JGF _ LPGI ; CORPORATION[J#I._ I PARTNERSHIPD# 1 LLC 1 71#i _ .t
COMPANY NAME:IHigh Efficiency U ADDRESS 1378 route 130 t
i.CITY Sandwich STATE l Ma i ZIP;02563 tTEL;.___-....,._-.,.._..___,._.._._,._a._......_.
FAX_..._.___._..W.r...__._.. CELLL LEMAIL Iadmin@high-efficiencyllc.comli
(_04
/
c)i