HomeMy WebLinkAboutBLDG-17-000070 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMif TO PERFORM GAS FITTING WORK
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•==_ 1=F CITY s. ,:.�'i�i i. MA. DATE 7/7 �%'f 1 PERMIT b /7-06120V0
JOBSITE ADDRESS J'/757W ie- , ' - 1 OWNER'S NAME C /,9_,"/i-;:,-,, . °f,1*..,
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`n OWNER ADDRESS: 1 J .. y4,'tv,,,, ;.G.Jii 5 ,,,,.,, ? TEL - -76 'FAx:
7.--Pr✓OR OCCUPANCY TYPE: COMMERCIAL 0.----- EDUCATIONAL D RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:3- PLANS SUM t t ED: YES❑ NO 0 FIXUTRES 7 FLOOR— 8snt 11 :I 2 3 i• 4 5 6 I 7 8 9 10 11 _ 12 J 13 14
BOILED. _
BOOSTER I I I J I I I I
CONVERSION BURNER I - t - II I { I _
COOK STOVE I I
DIRECT F VENT HEATER ER I I I 1- I I ! I
DRYER I I I I I I
i FIREPLACE r I I I
FRYOLATOR I I I I
FURNACE I I I I! I I I I i t
GENERATOR I i r I j
GRILLE I I1 _- _ I
( LABORATORY COCKS ( I I I I 1
„'u;(EEUP AIR UNIT I I II J l
OVEN 1 I I I I 111111.11111.1 I I
POOL HEATER I I I I I _ I 1
I ROOM I SPACE HEATER 1 1 I 1 1 1 I I 1 1
ROOF TOP UNIT I I
7E5 - I 1 I i I I
U !rT HEATER I I I ! I
UNVENTED ROOM HEATER I I I • 1 1 . I
WATER HEATER T I I I I• 1 I
a ..-c� � G;r,s//s :.._ I I I 1 1 ___II I -; 0 II
I I I I I I I 1� I II I s
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INSURANCE COVERAGE r II
I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of IVGL Ch.142 YES [Q ❑`-' I
II have checked YES- lease indicate theof coverage checkingthe appropriate bolt belo�i_
you P type � byLd.6 @ -�
LIABILITY INSURANCE POLICY 1 OTHER TYPE INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of tire V_ - -
Massachusetts General Laws,and Lhat my signature on this permit application waives this requirement. _
SIGNATURE OF OWNER OR AGENT ..
CHECK ONE ONLY: OWNER [ l AGENT 0
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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 end that all plumbing watt and Installations performed under the permit Issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFTT TIER NAME: g4.'G267_G_;v6f�cGORiLSg.LICENSE;: 97.?. SIG RE .
COMPANY NAME: Csj %/r-;n.:7 I/ r, �_ ''�
� F ��-�4-��iy C .:�. ,<_ ADDRESS: / S//t}-i/L'E ✓r t,o, .
CITY: &_,,-,v'--,-,.„ 1 ____I STATE: ( ZIP: O. -6;77- J FAX: Sf-795'a use
TEL' S�F''---3F, 8-`,6" ' CELL: Srfr G"7r/ y EMAIL: r, o4 Cv 3c�5 /cy,br)r-y.n e7
MASTER( IOURNEYMAN 0 LP INSTALLER 0 CORPORATION.❑#1 PARTiVF.RSHIP 0 it i LLC 0 it