HomeMy WebLinkAboutBLDG-19-001060 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
2 id CITY yn1N70c/.7%, MA DATE PERMIT#a/ A-/nyQ
JOBSITE ADDRESS r�.4 /rif/}/,t./ rc7\ ,ft 44 OWNER'S NAME L O/I/'TT/e
GOWNER ADDRESS TEL FAX
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[a/
CLEARLY NEW:0 RENOVATION: 0 REPLACEMENT:[a— PLANS SUBMI I I EU: YES 0 NO®-
APPLIANCES 1 FLOORS-i BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYCn_ATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM SPACE HEATER - -- - -
ROOFTOPUNITr,adf �� < t
TEST . _
UNIT HEATER �Jlr� 1 I1lB '
UNVENTED ROOM HEATER '
WATER HEATER
OTHER BL / ° tir
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL CIt.142 YES Cg'K0 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY p►- 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
T.!` 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 compile with all Pertinent Code and Chapter 142 of the General Laws.
provisionpr}— of the
Q} Massachusetts State Plumbing C✓C.
PLUMBER-GASFITTERNAMEGAC77Yer e°0444 LICENSE* //?S'r SIGNATURE
NW E-1f GF 0 JP 0 JGF 0 LPG!0 CORPORATION❑# PARTNERSHIP 0# LW 0#
COMPANY NAME est 77rCr .071#14t ADDRESS 7 P.h/r-rg vr/lik C
CITY ,44.44 !L4' STATE M0 ZIP end QC TEL •r0"X37 o2SS7
FAX CELL EMAIL, 4/277 r-'6 ' QC fC4/7 /YET
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 (MIC
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FEE: $ PERMIT ft
a
PLAN REVIEW NOTES
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