HomeMy WebLinkAboutG-18-1790 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1-42 LVP CITY Lf/. 7,2 •e4 • MA DATE / `27 PERMIT#/%'2 "/g'Od/r7D
JOBSITE ADDRESS Y /!4nt, 13 cu. 2 10 OWNERS NAME 0 fie—V4,0 o T 04&z
GOWNER ADDRESS 4 Y ,R 4t- . gent, R TEL Srci 911 A S'Y3 2 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDEIJTIAI _—
PRINT
CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:0 PLANS SUBMI I I EU: YES 0 NO 0
APPLIANCES 1 FLOORS-. OEM 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
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS ,
MAKEUP AIR UNIT
OVEN 1
POOL HEATER n;, E
ROOM I SPACE HEATER C
ROOF TOP UNIT I EP !7
TEST ._UNIT HEATER
LNVENTED ROOM HEATER I. 2 J
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 NO ❑
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 ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
`t� I hereby certify that all d 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 withall ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. k� t
PLUMBER-GASFITTER NAME LICENSE it 3 /70, Y SIGNATURE
MP❑ MGF❑ JPJGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0 it LLC❑#
COMPANY NAME ' '" 44e( E fP 4 A Teti( ADDRESS 2 o p n °SPe cr 4t -c
CITY C✓, >ef 2 . STATE"/ /4 ZIP a267 - _ TEL S'('9 - 922. O/f
FAX /1/sty""C CELL 922- 0/t v EMAIL /foMp'7
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
11- 1/C-4/7
// THIS APPLICATION SERVES AS THE PERMIT 0 0 4-6/
7/ SV/7 FEE: $ PERMIT B `rte A / i nn
` FLAN REVIEW NOTES 9,/o /�