HomeMy WebLinkAboutBLDG-19-000539 /A -P, P4 RC.,F I..'
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
->J CITY C.. :�< y 4x _......_. 1 .,._..._......-.��, LJ MA DATE, j 1 ---•I PERMIT OR -' i'
JOBSITE ADDRESS[.:27. .....R,... :..-., Ay?: OWNER'S NAME L�cl., , t<. !' ..-. :, -. �.:,
G OWNER ADDRESS f� -t . -1 TEll 7 f L1_'HS-jjI.?IFAX LL,,u:W.::.•., ,,...i
TYPE OR OCCUPANCY TYPE COMMERCIAL(] EDUCATIONAL LI RESIDENTIAL( `
PRIlVT
CLEARLY NEW:ri RENOVATION: I REPLACEMENT:IA PLANS SUBMITTED: YESH N0
APPLIANCES 7 FLOORS-4 satin 5 6 7INN 10 1t
BOILER ----1
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_ I . ._„1, _.I I _..._.
BOOSTER I` u,a)l
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER i ] i I I( ii „i I
S�vs„ ,..._1_ ..•i5 S P .1 S ..�A arti .4ti:.-
FIREPLACE 1i
FRYOLATOR
FURNACE ;- . _. I :1 1_ 1"_ ,yi
h
1 GENERATOR ( i i- G .�:37 I -i I
.6..
INFRARED HEATER I I(".::,. I I� . ..!i . I _ i
MAKEUP AiR UNIT I ..._-.�I� -,- 1t I r 1_ �i
LABORATORY COCKS ! M I
OVEN . - f` s _ �- 1 - ,'„1 1.- ....I {..... i
POOL HEATER i _ I -._.+ ^_i
ROOM/SPACE HEATER ' I l • .• fi -- II.. 1 .. _1 .. IL.. J
ROOF TOP UNIT I.... I.,..
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER i" ! i� .l
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INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES (;.j>NO L.i
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 11
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 El AGENT (,,,,I
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are tr nd acgdrate'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 i nae with atMMMiiiPPPertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 'y!
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PLUMBER-GASFITTER NAME L. 4( G c j,j,. „b,x,_ 1 LICENSE#E7Loi f • SIGNATURE
MI CI MGF ID JP 0 JGF 0 LPGI0 CORPORATION C� :, PARTNERSHIP(�,:J# _ LLC #
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COMPANY NAME °` pya ADDRESS '° ' " d�Jyl A�� pg y'cy�' - lJ r r
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CITY .. ''' a,.?,;,x, ::, w,,. STATE Lad ziPP 4.(s, Q° °. m Tt.[?OS- 3.1,-/= 7.1-02.....j
E...>.,..:,.:�1. -.-...I CELL( 1 FAX EMAIL L.., ., 3.1... `..m.x.s., w" ....... .1...+e—cae 1