HomeMy WebLinkAboutBLDG-19-1334 etj• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WOR
CITY SAM 0 t/ MA DATE t 9- 20)r PERMIT#12ge n'00I%
JOBSITE ADDRESS t// -Rim Ay S• y OWNER'S NAME n X.0 D s'fgpLT
GOWNER ADDRESS TEL 50f'— 76 AX•
_�_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS-I. BM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 4- 9,w_ CvM.8p / I
BOOSTER
CONVERSION BURNER -
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER • 1—CC I V
ROOM I SPACE HEATERis
ROOF TOP UNIT
•
--
INVENTED
TEAROOM HEATER �u L _
UNIT HEATER
WAT
R
��•` TME d�6 IJ
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NC)
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE II4DEMNITY 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,and that my signature on this permit application waives this requirement
'- z" " '� CHECK ONE ONLY: OWNER 0 AGENT 2"/
SIGNATUR 0 SWNER 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. //JJ to- V
/ —
PLUMBER-GASFITTER NAME LICENSE# W.,,AT RE— p�-7
MP❑ MGF❑ JP I' JGF❑ LPG;❑ CORPORATION El PARTNERSHIP El# LLC❑#/ / / l /
COMPANY NAME ADDRESS
CITY panJA S STATE ' ZIP 0163 TEL/ t .9arr Sd`�✓
FAX CELL EMAIL .
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERM T 0 0
•
FEE: $ PERMIT# F- 1// 6,9
FLAN REVIEW NOTES /C •
iiv/r _
•
•
1