HomeMy WebLinkAboutBLDG-17-005578 �--` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY UV-' Y;.r-n,..r-.. MA DATE 'CI PERMIT#/ VL1''/-7—04. 2I
JOBSITE ADDRESS IPA C�ac c L }� OWNER'S NAME ' e14 S y".,ncce -
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Q,/ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7. FLOORS BSM 1 — ...2... 3... 4 5 6 7 8 9 10 T 11 12 13 14
BOILER I---__._
l --
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER _
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR __._._.-._..._...
G
ILLE
RRARED HEATER 2Q1�
INFRARED
LABORATORY COCKS
MAKEMAKEUP AIR UNIT l_�F:/"
" / ()f Sr
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER -- _..__._..._
WATER HEATER
OTHER
-- ��— INSURANCE COVERAGE _.—
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ®NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ 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 ❑ 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 hasLcf-uiyknowledge
and that all plumbing work and installations performed under the permit issued for this application will be in Hance with all Pertinent provision o e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Cf ct Q 'IShop LICENSE# f-5 I p SIGNATURE
MP[r MGF❑ JP❑ JGF❑ LPG❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME *tC �} 'FPei Ctec\Cu‘l n ADDRESS i37F f iOU�'P i`0
CITY San a-Up Ch STATE�"1 , ZIP O9,5(03 TEL Of3- S- 669(5
FAX CELL EMAIL v r�I Lj d tc1"}` e]i-1 Ci �'LP f(( . co
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