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HomeMy WebLinkAboutBLDG-24-588 �` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT T PERFORM GAS FITTING WORK � �o�N0 C-2'�1- Sid CITY i-g0 1 1i4�, DATE CT `� PERMIT# -r�•. JOBSITE ADDRESS OWf R'S NAME il l /V r---�G j OWNER ADDRESS TEL FAX TYPE OROCCUPANCY TYPE COM�IERC EDUCATIONAL ❑ RESIDENTIAL❑ PRINTCL`�AY NEW:© RENOVATION: REPLACEt�9EIJ'(: �— PLANS SUBMITTED: YES NO❑ 2 3 1 5 6 1 APPLIANCES 1 FLOORS-4 BSM7 0 9 10 'I'I 12 '13 14 BOILER BOOSTER I CONVERSION BURNEP, _ COOK STOVE DIRECT VENT HEATER DRYER —� i FIREPLACE ' 1 FRYOLATOR FURNACE 1 GENERATOR I.1• INFRARED HEATER I LABORATORY COCKS - I r T' -y MAKEUP AIR UNIT R_ F d 78 �t:7. V —\,. I �1 OVEN . . —� POOL HEATER ii eC` OA 2024 ROOM I SPACE HEATER ROOF TOP UNIT r ntz TEST • Bw��lrv�r .' 'rrvaEti1- UNIT HEATER �By - r --- UNVENTED ROC!f! HEATER i I---� WATER HEATER OTH-R l INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES 0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA . Y 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 i Massar_hus.etts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 71-• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur e 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 I rtinent provision of the `- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `E PLUMBER-GA ' ITTER NAME ,q.t AJTOPO��( y '#/57/ / SIGNATURE MP I ,IGF JP JGF LPGI /I CORPORATION It �''J PARTNERSHIP # LLC # pc=f--/—/ S Z tri17MW ' COMPANY 7JM E NDDP.ES� CITY CV STATEMIt ZIP OZ 73 TE.1„.5 7(i.039(1 a FAX CELL EMAIL GU(- 'q c \ ilf 3 I 1 I G1 5 4 I 2' I i I 4 I .1 I 4 I V. I - t I 1 1 I 1 4 I r.r1 w 0 Gx1 Lu S F- r'C au a O Lu - Q CAA aq I— G v 71 Q. <g tia 1 LL- i C ., 4" 1 0 I E i W rio I z Q 0 b g I I 1