HomeMy WebLinkAboutG-17-3259 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
tell) CITY r//21440 L171.1 MA DATE (2114-421110 PERMIT# 412bra'4(3
JOBSITE ADDRESS .81/5— g ' c- ,S YAa vvlO L,T t'�UNTlt-
O ER'S NAME 3A /FAA. dZ FAC ry 60
OWNER ADDRESS aaKSS9 CLMAlenhq vt0 o2137 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO to
APPLIANCES 2 I nna^ BSM 1 2 3 4 5 6 7 3 9 10 11 12 13 14
' DECEIVED
CONVEsI 'NL�70 2016
COOK • 0
DIRECTEl IT BEATER_
1• 6UILUIN.a DEPARTMENT
FIREP
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS .
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST . _ L
UNIT HEATER
UNVENTED ROOM HEATER
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 22 NO 0
I F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND ❑
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,arid that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
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
3- and that all plumbing work and installations performed under the permit Issued for this application will be In corn i nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPG'❑ CORPORATION❑# �oI�RTNERSHIP❑# LLC❑#
COMPANY NAME eva i S S 2.A2S ADDRESS o A 3 70
CITY y 21'i'l r par STATE/,r''f k ZIP 02471— TEL se -2742 S'd
FAX CELL EMAIL OJOLSy4'2 (QM£CiAA/2 .,v£i
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/GAS TINS E T OON NO'�'i1S, THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
W '✓�J "/J6f Yes No
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/ THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT# y „ y V
45 .
PLAN REVIEW NOTES
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