HomeMy WebLinkAboutBLDG-19-005437 '.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTINGWORK
�Til
` CITY ( env.N Vs MA DATE 3 '--9 - 0 PERMIT# 6417 79'00)7 /17
JOBSITE ADDRESS o)U 5 ego l ( d.G(t OWNER'S NAME 2 g_ �,(J t A Q/v.2fG n
OWNER ADDRESS TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL®-----
PRINT
CLEARLY NEW:❑ RENG\/ATION: ❑ REPLACEMENT:0'"--- PLANS SUBMITTED: YES❑ NO❑
.' BSM 0
APPLIANCES� FLOORS 1 3 4 5 6 7 9 10 11 12 •13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
RYER
i DIRECT VENT HEATER
FIREPLACE --�
FRYOLATOR FURNACE
GENERATOR 11111
GRILLE ■ ■
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT C I I-
OVEi
POOL I HEATER
ROOM I SPACE HEATER MAR 2 0
ROOF TOP UNIT
TEST _.. . .. _.. . .. DEP.. . 1 .. r;1.Nc3
UNIT HEATER I —
UNVENTED ROOM HEATER
WATER HEATER
OTHER 1
I
1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ErNO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E"--.' OTHER TYPE INDEMNITY ❑ BOND ❑
1
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.
I
.1 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 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.
`4 O/,m.Z. iz
PLUMBER-GASFITTER NAME ei v S "1 6''a LICENSE# rrka$64 SIGNATU60
MP 174-'MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME 0_(� {e0tril7 e4- ADDRESS I\ C&tR.P Zr."--
CITY LV_ 661 Z n\o j,r\ STATE 1 ZIP O a-6 3 TEL I
FAX CELL 910-g34,-0-7 `' ''( EMAIL &&/I-L. \6-51 Q a c ( Cr,--,
i-%'1F C16 - 0 �U-
I
I
1
G1
0
I 0
1 PI
I -
e.
1
I �,
1 r
I
I
I
it
I c
w O
I C ut -
i = a rA
I - C e`�
GO O.- -
0 > ..
I _w
Q
-G=w'' C.>
Zi
Lt3
I 1-- LU
U-
I
C
7
t-.
0
LEI
lY
()
rA
cn
u-1
C
g
I
1
i