HomeMy WebLinkAboutBLDG-18-005158 = '`� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTU G WORK
��_kir-.�•<y~ CITY Ylit,nevOuli-rl MP. DATE �O�AC)/ 1( g PERMIT
�d. JOBSITE ADDRESS S G1PJV\,,.,car St" OWNERS NAME k y We We,N
GOWNER ADDRESS S 9 ae_ax,�l iX�ID t' TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL["r
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 1K PLANS SUBMITTED: YES❑ NO[.�-
APPLIANCES 1 FLOORS.— BSM 1 2 3 4 5 6 7 8 9 10 111 12 '13 14
BOILER -7---- ___IBOOSTER -I
CONVERSION BURNER, _
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR -
FURNACE
GENERATOR
GRILLE I
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER "`
ROOM l SPACE HEATER D
ROOF TOP UNIT
TEST ... . . .44 .. ---
UNIT HEATER
UNVENTED ROOM HEATER . .fr---1)- ',-F-- f.6if
WATER HEATER
OTHER ' -
•
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES 2-NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [V1' OTHER TYPE INDEMNITY ❑ BOND ❑ 1
I
• (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
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT j
t` I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate tot ;nowledge
`— and that all plumbing work and installations performed under the permit issued for this application will be in complianc. ' ertinent provision o he
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LIJ
PLUMBER-GASFITTER NAME Y1 ,L,io S;L-,V4 LICENSE#3/,39,s-v ,E
MP ❑ MGF❑ JP"JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑It LLC 0 It
COMPANY NAME_S1L.v4 PLv w&,i& cjir 1 ADDRESS 1ss SuLi3uky 1..4
CITY 4-y,0 VA/;
J S STATE,M/; ZIP �,/2�,( TEL
FAX CELL7I-7 kt.3 017Gj EMAIL V 4,G,Lt.L9 MGit Q 4t4, co .
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