HomeMy WebLinkAboutG-19-853 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
cr 4; CITY kt i tna PAI7N— MA DATE 9/V.[ (IJI PERMIT#D O6%/"OGVVSf J
JOBSITE ADDRESS 88 •\a 1-10 OWNERS NAME A Irnorlit 2 GY`Qst
OWNER ADDRESS 8 VAt2_, Lu TEL Lei'Zd$11FAXTYPE _____
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OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL cg
CLEARLY NEW:®.. RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-- ECM 1 2 3 4 5 6 7 s 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN :. :. l. .- Y ` , N : tr '
POOL HEATER • I -
ROOM I SPACE HEATER I I
ROOF TOP UNIT
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. . _ ..- .- . . . • .- .
! - -- I -
UNIT HEATER 4 _r
INVENTED ROOM HEATER . _
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MGL Ch.142 YES CO NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 0
SIGNATURE OF OWNER OR AGENT
tic. 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 compli w�._ P -nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME UCENSE 432a SIGNATU•
MP ❑ MGF 0 JP at JGF❑ LPG( 0 CORPORATION❑4 PARTNERSHIIP�❑# LLC 0#
COMPANY NAME J •t'De 4na,� otv t rn3 ADDRESS -Ko ` c,4 $r 1�
CITY S• lCmrno +, YYIA- STATE in Pr ZIP oVo&`t TEL •SCIS'-22{-S2S]
FAX CELL 5 6-ZZ1-Qr1 EMAIL atCic..url-ytc tP ttmalrL-Cdr
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ROUGH GAS INSPECTION NOTES IBIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 (///� '�//�/J
FEE: $ PERMIT R P7�/ `� �///
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