HomeMy WebLinkAboutBLDG-19-000246 s° MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 1'Astt�AoJk �T IAA, fr
DATE PERMIT bIYT"/ Nycy
JOBSETE ADDRESS `2/1 3 Sp1 sr' OWNER'S NAME 6402/ SeELE
OWNER ADDRESS 7
Same TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[a]' •
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CLEARLY NEW:[r RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 0
APPLIANCES 1 FLOORS-, 851 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
POOL HEATER •
ROOM(SPACE HEATER
ROOF TOP UNIT
TEST • .. ._ ._.._ . . . --- --
UNITIT HEATER
(INVENTED ROOM HEATER
WATER HEATER
OTHER
•
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of M .111 '24--YFSr . E
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE�/ BY CHECKING THE APPROPRIATE BOX BEI rW �`Bp
LIABILITY INSURANCE POLICY M •
OTHER TYPE II4DEMNITY ❑ BiND 4E. 38
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage req:ire bnv hapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requiremenL i a tS r'?€3 #f r Gr9
J CHECK ONE ONLY: OW IER 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 comp8 ' all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LLIFI
PLUMBER-GASFITTER NAME P062- PAOCQ✓1 LICENSE# 26'102. SIGNATURE
MP❑ MGF❑ JP IJGFFD LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
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COMPANY NAME ?. 620ea.4 ADDRESS ( 3? Pe:Ace akcid9' at)
CITY eet4AelLgifie STATE IA 4 ZIP 0243 2 TEL Mb 490 .eo750
FAX CELL EMAIL
le G. AS S'. O► ► 4 _ THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
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�� THIS APPLICATION SERVES AS THE PERMIT 0 0 J��� �' '
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