HomeMy WebLinkAboutBLDG-17-004465 0 a- /b7era!31333 2—/i/en c" ) FIT
.4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ma) CITY Jo , y04 -nloott1 MA DATE 3 —' — /7 PERMIT#/f-al-/7'OG 91716;
JOBSITE ADDRESS fl &,t, e.¢Y OWNER'S NPM&" C Lyre 2:4-ea no-q
OWNER ADDRESS y2 -%c,7Lines 4427 TEL FAY,
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL--
PRINT �,�
CLEARLY NEW:lam' RENOVATION: 0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
APPLIANCES-4 FLOORS sSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE - 1
DIRECT VENT HEATER -
DRYER /
FIREPLACE
FRYOLATOR
FURNACE J
GENERATOR
GRILLE -
' INFRARED HEATER R E a» t_I;
LABORATORY COCKS ' "1
MAKEUP AIR UNIT
OVEN / • MAR e, C r
POOL HEATER • _ p�
ROOM I SPACE HEATER u J r (Oy- 0 i I
ROOF TOP UNIT
TEST . _ .._ .
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
• LIABILITY INSURANCE POLICYI / 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
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# /26,2 y SIGNATURE
MP❑ MGF 0 JP JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC❑#/707 y
COMPANY NAME /Gry,-r ! F_ _sen Aev-e ADDRESS
CITY A'- y4 R• STATE/"J/i • ZIP OZO 2 3 TEL 612$- 522-an
FAX M.N A CELL .•St0$- 12 2 -0/e5 EMAIL //JON
ROUGH GAS INSPECTION NOTES THIS PAGE FOR 1NSEECTOR USE ONLY FINAL INSPECTION NOTES
Yee No
012/ ,f/^ 4 g`� THIS APPLICATION SERVES AS THE PERMIT 0 0 Fr/AMC r
As /J
/i t a- ?jai/ /7 FEE: $ PERMIT ft / � 0/1 �`
ELAN REVIEW NOTES
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