HomeMy WebLinkAboutBLDG-17-002358 MASSACHUSETTS UN FORWJ APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY t4/,2I/A,14I,. 1, MA. DATE _ // // !/( PERmrr Fhb-/7'6vo75
GJOBSITE ADDRESS l/ - ,�;✓ ,1cs:',1 r• OWNER'S NAME i111 �i - 14-'f i
OWNER ADDRESS: VY 7 L•cvG 7// '0Z✓ 4) TEL: ecs'— 7-,/7/-/ FAX: --"
97 r✓O-a OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL Q RESIDENTIAL(
CLEAN NEW:❑ RENOVATION:Q REPLACEMENT:[3-- PLANS SUBMI t I t0: YES❑ NO EL--
FIXU T RES 7 FLOOR— I esmt 1 I "! 2 3 I. 4 51 6 7 8 9 10 11 12 13 ( 14
BOILER ( 1 ( _
BOOSTER I I ( !
CONVERSION BURNER I 1 - I .
I COOK STOVE ! I ! ! I
DIRECT VENT HEATER
iDRYER
I FIREPLACE I I I
FR Y OLA OR
IFURNACE I I I I I I I l I
GENERATOR
GRILLE I
L LABORATORY COCKS
I M KIRIPAIR UNIT
` OVEN I I ! I l ! I I
POOL HEATER I I I ( ! ( ( ( I
} ROOM I SPACE HEATER I f I I I
ROOF TOP UNIT
I TEST
I UNIT HEATER ( I I
UN\ENTED ROOM HEATER
WATER HEATER
I I I I I I I I I
( I I I I I I I I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 1<1O Q
If you have Checked YES.please indicate the type of coverage by checking the appropriate bolt below.
LIABILITY INSURANCE P-OUCY 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 Lav s,and that my signature on this permit application waives this requirement:
CHECK ONE ONLY: OWNER ❑ AGENT
t ❑
I SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)matting this application are true and accurate to the best of my
Knowiedge 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.
PLUMBER!GASFI ttER NAME: 1. lh-�h Q.ivGile-sorzrLQ 4 LICENSE i#r _.. i SIGNATURE
1�� s...._. 1 .,. Lid
r h i ADDRESS: / 1 /1'Ih�-Yh eV'
COMPANY NAME:}:}� �`T' ��Urr �lv(,- �. ���-�4-7iivC..
CITY: I vi rt po f I STATE: I' , ZIP: 0.,/6,77 A FAX: [P7a:77V6.V371
TEL: G 3Ff `: : CELL: _SW p?any EMAIL: ',g44h 3 l hi n e7 1
MASTER BiOURNIl'14tAN 0 LP INSTALLER 0 CORPORATION-0#=
PARTNERSHIP 0#)ILLC 0#►