HomeMy WebLinkAboutBLDG-19-006487 MASSACHUSE I I S UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -
CITY /„1-; AO t •I 3 MA DATE 5-4//r PERMIT= /%G/X�'�(F"OC�4 4/67
JOBSITE ADDRESS: C-70 ►. Z N Q7 L'Q4-te -OWNER'S NAME Rio Nifie/'
GOWNER ADDRESS 1 g ss;!_' /me- 14 P rK0,7414 T E w?- - 7g Sy ;FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL K
PRENT I ____ •
CLEARLY NEW:I RENOVATION: REPLACEMENT: PLANS SUBMITTED '°_
APPLIANCES T FLOORS- I askt 2 3 I a 5 j o - i
BOILER I s, _ ...� - ._ -_
BOOS I tI< --
CONVERSION BURNER4. ,. Y —
COOK STOVE - - —
REGT VENT HEATED
DRYER i -== -. ; .. .t_ __ - ----
FIREPLACE
FURNACE I I
GENERATOR + —� v
-
GRILLE 1
INFRARED HEATER _
LABORATORY COCKS
�i. _SY ,_ 'ate— ---..-_. _ ...-..
MAKEUP AIR UNIT — _
CVE.N
POOL HEATER
1 ROOM SPACE HEATER f ___
r'
ROOF TOP UNIT I I-- -
TEST ' i .. -.. -.__
3f 1 T HEATER
s
UNVENTED ROOM HEATER 1 �'
NA T ER IHE.ATER ,; ; .
f ,
J^ .HER ••-- - - - --.
f
p
INSURANCE COVERAGE _
i have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES It NO
iF Y Ot CtiLCie u YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chanter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER __I: AGENT
SIGNATURE OF OWNER OR AGENT _
hereby oertify that all ce the details and information I have submitted or entered regarding this appncatior*are true and accurate to the best of my icnowiecge
and that ail plumbing work and installations performed under the permit issued for this application will be in Dompliance with ail Pertinent provision of'hE
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
- — Y-"^----��- ____
PLUMBER-GASFI-TER NAME ,_, ;LICENSE Of i,4 Ro SIGNATURE
YIP MGF JP JGF - LPG!- CORPORATION . # 3_6,1'a c.,PARTNERSHIP 7,# C_j#
COMPANY NAME:!OZxattvetl; � .. _ ADDRESS ..:'j 1 e. - .s kY},
C1Tti �� .` - STATE AVI-_ZIP c i _ TEL ,5-. z:-G..i(..(" _
FAX 5_1_77:0s'cj. =CELL EMAIL .L.SG & C/C.0110E1/0.1_I_t C..p.t'[.
o
i
i