HomeMy WebLinkAboutBLDG-20-001978 "' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
p. p` 6' CITY Kiteipie-keT. MA DATE fo/?/ 7 PERMIT ft Il46" '6d//73-
JOBSITE ADDRESS - ' ll/1 14-, ddd OWNERS NAME M -7
GOWNER ADDRESS TEL A.
TYPEOR OCCUPANCY TYPE COMME .,IAL❑ EDUCATIONAL ❑ RESIDENTIAL L�
PT
`�
CL ABLY NEW:❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS—I BSM 1 2 3 4 5 6 7 5 9 10 ii 12 13 14
BOILER _ — 1
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYDLATOR
FURNACE I�_
GENERATOR
GRILLE _ _
INFRARED HEATER
LABORATORY COCKS —�
MAKEUP AIR UNIT
OVEN (r)
POOL HEATER # 0ar -ROOM I SPACE HEATER
ROOF TOP UNIT
TEST -..
UNIT HEATER _
UNVENTED ROOM HEATER
WATER HEATER /
OTHER
- - I
INSURANCE COVERAGE ., ��
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LgO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA . Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ Bow ❑
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage require Chtiapter '42-of the
Massachusetts General Laws,and that my signature on this permit application vwraives this requirement 3377 Z4e6,00,..)
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
:.1-• 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 comp€€ance,with all Pertinent on o'
Massachusetts State Plumbing Code and Chapter 142 of the Ge ral Laws.
`1 _
PLUMBER-G ` ITTER NAME k i l/ a 0 s LICENSE It l i it.g.7 SIGNATURE
MP I MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION S PARTNERSHIP❑41 LLC❑#
COMPANY NAME , f��
� rt Le bt..C7 ADDRESS ,U ZOk
CITY Al Palfre/t STATE ZIP 0.16,6( TEL't° ) 3 -5
FAX. Z6 tid—Y3 CELL 36' 7 3&S EMAIL/11/ .mg) / -d Gil
-4C
I
1
I
0
Z '' ..'.
ill/ill
I Li
1
1
i
1
I
I
1 w LO
1 I- v.1
w
0
i ) E
i I-w
I.. tx -
I LLILU• >-
GO a
o
E. 1y
De
Iii
uU..
1
Ca
0
H
Z
1 P
C
I r4
Go
I �
i
v.1
c
1
C
I
I
1