HomeMy WebLinkAboutBLDG-16-004434 �. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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Q 'JOBSfTE ADDRESS' -2) Nit,-/ � — I OWNER'S NAME S i1 2i,'&/ --J
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U -Lul i o OWNER ADDRESS ; Jam°` ,c., ___ I T EL ._&,�5 1),73 1.FAX I
LLB ' rticii I OCCUPANCY'TYPE COMMERCIAL; EDUCATIONAL RESIDENTIAL
4iRI Y NEW: —( RENOVATION: —E REPLACEMENT: ......___EDUCATIONAL
' PLANS SUBMI I i t_D: YES J NO L
APPLIANCES Z FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 ' 12 13 14
BOILER __i __ _! . 1 __._J� ___J J __1_1_1. tr_— —1' -1
BOOSTER - 1- I 1_ I . ` 1 . ._ I-� •
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CONVERSION BURNER _. . I—__• 1 I t t_}_j _r -1' ( _ ... t._j
COOK STOVE __I • ! p: --.
DIRECT VENT HEATER _� 1 ( E--� ;'_1 ( I_� t_�_..__� H._. . .
DRYER• =- ' -- P. .. . - .. ._... 1,_.. . .. . I- l•_ I 1__I- _ 4 --.....4
FIREPLACE - - if -- I I- -I—1_J—1; . ; I___ _I I I -— L. j . I
• FRYOLATOR i t .� 1- E--f t. 1 .. i __I .—.(- _ 1. I---1
kJ FURNACE ( I. •1 Lill i r 1 .. —J I I 1- I J
GENERATOR - I .. . I-.. - t 1 ..1.._ .....I.. 1 I .. 1. I I 1 1.
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r GRILLE _—i i�J�! i i i`—J:_� 1 -i]._ J_-1-_-_]
INFRARED HEATER _ .. — ;-J (_ ' -�' � I—1 }--I` I_Li t
LABORATORY COCKS I } .. s _...I 1 I _____I__Li__,21—J 1 1
pMAKEUP AIR UNIT - r - -
OVEN '_I 1 i .. i:::_- i U . I-_I. 1 ___._J ....__Li 1 —(
ki POOL HEA I EIZ iJ—J. l I -1____ ___._ I.,____I—___J:_ ( ._.__1__..1 —. _ J; __I _1
ROOM/SPACE HEATER :-•- -I I, • -.I . .. . I I • • i I _...I._� I I -- I I i I
ROOF TOP UNIT I r 1 1_ i I -}._ I I . I. . '- I I
TEST ,_J i r ` (_ _J—___.1_.__I I i_f 1' I I
UNIT HEATER _ -1 1 I .1 - . 1 ! __i _�-.a 1 . 1: -.i
UNVENTED ROOM HEATER ! _ r_ 1 S ( I._-._i.--1_1_j I____1-�i I
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WATER HEATER - -
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OTHER= l I'. I,- -I ._ - __:___;11. -.
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INSURANCE COVERAGE
CNO I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES D
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVER?:GG Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY j BOND (li
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 :3 AGENT J
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 co pliance ' all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME _- S5-4 �I LICENSE#"�a'� S NAG,SIGNATURE
MP NIGF Li _J JP JGF�j LPGI :Zit
V'7/2' z PARTNERSHIP``_ :_J#11# .LLC ,__. -
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COMPANY NAME. C. 41 A9AJ4 I ADDRESS: `� -
CITY j .. � �c...?- ` '..-.. .. ._- .. I' STATE.(744.1'ZIP e9 ‘ TEL lac � 9 7l t
FAX' I CELL:,] 1 W EMAIL: E
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