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HomeMy WebLinkAboutBLDG-20-003320 ICU 9arCel i ?() MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MWVA���I..� _ - MA DATE i: ._nald PERM! `i ' . �.� __�3- CITY I 1 1'� i JOBSITE ADDRE S ,.../ Ir. __ a4._1 OWNER'S NAME (44 ' GOWNER ADDRESS TEI, $FAX . __. _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Li RESIDENTIAL PRINT CLEARLY NEW:© RENOVATION:® REPLACEMENT: i PLANS SUB TTED: YESQ NOD APPLIANCES 1 FLOORS- BSM 1 2 3 11:11 5 6 7 B 9 10 11 12 13 14 BOILER !M, BOOSTER IININIENNIMMWEM.___,__ N CONVERSION BURNER ',� MJ COOK STOVE MIMMIIIIMMIIIRMINIEMMIIIIIIiiiINIM DIRECT VENT HEATER MMMIIIIMMM DRYER �._.M _�MM'' FIREPLACE MMIIIIIMMINIMMAIRINIIIIIISMMINIIIII FRYOLATOR MMMINKINEMINIIIIIIIiiiiMIIIIIMINKINIMIII FURNACE GENERATOR GRILLE _ I ' INFRARED HEATER IIIIMMIMMM. . IIIIMMIIIIIIIIIIMiaM LABORATORY COCKS IIIIIMM- IIIIIIIIIIIIIIMIMMINSMINKIIIIIIII MAKEUP AIR UNIT MIIIMNEMIIIIIIIIIMEECIIIIMMMMINIM OVEN MMMMMMIINIMM.iitMMEKMM POOL HEATER IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIINIMMIMIIIIIIIIIIIIIIIIII ROOM!SPACE HEATER IIIIIMIINMIIIIIIIIIMIMIIIIIIIK --- - ROOF TOP UNIT MINEMIMMIIMIMMINIMIIINiiiiMIMINE TEST MNISMIIIIIMMIIIIIffialislilIMMIIMIIIIIII UNIT HEATER IMMIMIIIIIMMIMIIIII_-. MIIIIIIII- UNVENTED ROOM HEATER IIIIIMIIIIMIIIIIIIIIIM IIIIIIIIIIIIIIIMMIIIM WATER HEATER IIIIIINIIMIIIIIMMILIIFMJIIIIIIIIIIIIIIIIIIISMIIIIM OTHER I MIIIIIMIIIIIIIIMMIIIIIMIIIIIIIIIIIIIIMIIIIIIIIIII IINNIIMISINNIMIIIIMIIIIIIIIIIMMMMMMIIIINIIIIMINIMMMIIIIIM INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES EqNO _ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY 0 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 Li 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 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 complia Pt provis' he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4. 1AP PLUMBER-GASFITTER NAME a C G r)_ 5 . R_, e d z.l..l_._....._.___;,LICENSE#I.ZS YG SIGNATURE MP r4 MGF LI JP Q JGF j LPG]0 CORPORATION D#L __j PARTN ERSHIP#( .. .._____._ LLC J#___.......___...___..___ COMPANY NAME: C c,rI_..__t._ IRL e d e I_I r.__Son I ADDRESS r 7 7 S is%I c, arm. S t re e - CITY USI•erv1 Ile STATE 5(A-- Has- _6235(0 ._ FAX 1 CELL ;EMAIL