HomeMy WebLinkAboutBLDG-25-273 , -
MASSACHIEETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS RTTING WORK
• CITY' S. `P9-rtvidaftl ) MA DATE) S/S/S— 1pERMfT#DZDG-Z-4-- 2-'73
JOBSITE ADDRESS a-ct Pfl-f-tkerS/•/t'k Rol I OWNER'S NAME ,\t°SSIA LAW' L I C .
GOWNER ADDRESS'97/idis K./ u An hI h?;tf fkrT AU- i T (40-90'5-7('gy f AX
TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL Q RESIDENTIAL 23,
PRINT �
CLEARLY NEW:( RENOVATION: REPLACEMENT:6,.a PLANS SUBMITTED:YES D NO®
APPLIANCEST. FLOORS-. )BSM j t 1 2 1 3 ) a i e 13 7 e ) 9 1 10 1 tit f2 1 13 1 14
BOILER I , h
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER i.
DRYER f * t •
FIREPLACE
4
FRYOLATOR Ilib. i
GENERATORFURNACE I
- I C L b e a
GRILLE
INFRARED HEATER lib' 91 20A
LABORATORY COCKS M
OVEN . I
MAKEUP AE2UNIT 00111F8k,UhhARTvNT
POOL HEATER r ®7
ROOM!SPACE HEATER v.
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER-EATER 1
OTHER, s
4
Neuman COVERAGE
I lava a caseentiiidlhr asuranCe policy or Its subetm tldequivalent sift masts the requirements of MGL Ch.142 YES gm D
I FYOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY'S OTHER TYPE INDEMNITY BOND FT
GAINER'S INSURANCEWANER:tam awarethatthe licenses does not have the insurance coverage required by Chapter 942 of the
Ywadmaeib General Lawn and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER EA AGENT rzl
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the challis and information I trace submitted or entered regarding this application are true and accurate to the• u my knowledge
and that all plumbing work and hrsfallatfons performed under the permit issued for this application will r compliance with all Pertinent•4•. of.r
a
Meechusetts State Plumbing Code and Chapter h42 of the General Laws. '\� ='
ITr'PUIMBER-GASFER NAME J.L-w ee, r. y i LICENSE#' SIGNATURE
MP'W' MGF D JP D JGF®LPG 0 CORPORATION®#Laaaraci PARTNERSHIP0# _ _I LLC0#
COMPANY NAME: - _. � .__.J ADDRESS__a.s-.%_C.as.&...._.
CITY I /. �/ L�o�.. .�,. __ STATE AA• ZIP
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