HomeMy WebLinkAboutG-18-6557 e==
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY � /L-/�nc4 T n MA DATE /NO PERMIT 7� /
�� JOBSITE ADDRESS W i k /6-S l .bent ir,,, OWNER'S NAME
GOWNER ADDRESS 6L 47O/rrre77 etto gen;n , TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL❑
PRINT 1/
CLEARLY NEW:❑ RENOVATION:1:1REPLACEMENT:g PLANS SUBMITTED: YES 0 NO(
APPLIANCES 1 FLOORS 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
FRYOLATOR
FURNACE 1
r' BATOR
(i FE
�J iFRARED HEATER
\ ` LABORATORY COCKS
S. MAKEUP AIR UNIT RECEIVED
,
OVEN
ROOR 2018
ROOMM/I SPACE HEATER MAY z-
ROOF TOP UNIT _
TEST PUILDI VG 6EV'AK I'Oitry
UNIT HEATER
M °! -- ——
'•1 UNVENTED ROOM HEATER
N WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES'4 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
IN 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
1L 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 cop Alliance with all P nent p 'on of the
Massachusetts State Plumbing Code and Chapter 142/off the GeneralalLaaws.. f Yn A'^✓ /0
PLUMBER-GASFITTER NAME F'bOM� 1-0t1�r//il LICENSE#m2S,Ai \TIIfWB"i SIGNA .RE
MP'MGF❑ JP' JGF❑ LPGI❑ CORPORATION-# (4Q0G PARTNERSHIP❑# LLC❑#
COMPANY NAME A VIC t14-4-774614 C! Nle' ADDRESS 30 Mei cCA-
/
CITY itin0�� STA�T�E7 9 ZIP ben?-- SG
TEL LF'673?4?0/
FM CELL 'o(57-I6-Ng EMAIL tyo,,.t,yt/ca,c7a3 afill (Al
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 9 0
FEE: $ PERMIT#
PLAN REVIEW NOTES / ,fr (�J7
7/6-177-
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