HomeMy WebLinkAboutBLDG-18-000614 —mo
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
o
c77
„/ CITY .. . , � � MA DATE .
PERMIT# UIT/'4oa 61/
JOBSITE ADDRESS _ 6. _Lai ,&l,,,._._._.»,_. : OWNER'S NAME ,
GOWNER ADDRESS ma TEL _ FAXI__ -----I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL
PRINT
CLEARLY NEW:LI RENOVATION:IE REPLACEMENT:lia PLANS SUBMITTED: YES NOD
APPLIANCES 1 FLOORS— I BSM 11 2 3 I 4 5 6 I 7 8 9 10 11 12 13 14
BOILER
BOOSTER r l if
°i
CONVERSION BURNER 7 fl V 1 ,r ..i i,.,. .. ._xx:11 L I ._71.. F 1,
COOK STOVE J
! _
DIRECT VENT HEATER 1 r i _ � i ..,, .
x,ti ...� _ l I , I I _ a.,.. _11,
n
DRYER
FIREPLACE il ,.��' . ' V' a _.�€ � ». ..:
FRYOLATOR ? .r i i+ i x l I,� 71 ._,x .: x III, _s.:
FURNACE _' J l 11 F I Li r ai _
».� tom; �v
GENERATOR r. 71 �1, , A # .a _' . �, .., _
GRILLE tl
INFRARED HEATER , .. 1. ...1 1 I__.,, i 11. 1. I(, 1171
LABORATORY COCKS i_ -III t ,-' C�i _F
MAKEUP AIR UNIT fi I `�
., I� .... IM. <. I4 _l OVEN I' f ; III � ,m
-
POOL HEATER . I i.
i �
ROOM/SPACE HEATER
ROOF TOP UNIT � _ -- -t II
—, .,. „ s- . ,
TEST LT. i _ _. � .a_k ..S. � .�_ . I. .A
UNIT HEATER il 3 1 xj
UNVENTED ROOM HEATER r .i I_ 0 w t tE, ti g zl E i .» I Jr:
WATER HEATER ; .. E
OTHER i 1,
uwrec+me-»w» v .ix wxx,-�' w ,.. y g: u..-.., {..-. .e ..v,
�` _ li i � .
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO DS
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY PI OTHER TYPE INDEMNITY l.. BOND 0
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 0 AGENT
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 a •. a- best of 'no -dg-
and that all plumbing work and installations performed under the permit issued for this application will be i om• vit �O nt* .1 -
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME f ` LICENSE;r h IGNA II•'
MP gO MGF D JP 0 JG; #
LPG' CORPORATION # ,,�.,:. PARTNERSHIPD#__ _ iLLC11#r-..:
COMPANY NAME: . , 1/24) Lau
CITY
�� I STATE ZIP L 7 TEL =.,1
FAX , •,. CELLq,.4,jEMAIL�
r
V
C
\'•
1�
V