HomeMy WebLinkAboutG-19-1063 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
- CITY '/AtMO�AAA DATE pp
oL� 7i PERMIT#AZ-/1f' /!..�p
'00/0/41
JOBSITEADDRESS )Jit C i R/tu i T ki OWNER'S NAME/,ARIA fttk 4his
OWNER ADDRESS Y Cf 2G t A 1/ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 9
PRINT
CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:C - PLANS SUBMITTED: YES❑ NO[gam
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13it -
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER .
DRYER
FIREPLACE —
FRYOLATOR
FURNACE —
GENERATOR —
GRILLE
INFRARED HEATER y —
LABORATORY COCKS -- � 7I Ni /At IA
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MAKEUP AIR UNIT r C Q - _t' s
OVEN
POOLHEATER 1 U ,/1,. Aid t
ROOt,A I SPACE HEATER �'-
ROOF TOP UNIT
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 Cb.142 YES EI NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY Vs 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 a.., is; . - •e- . ••. edge -
3- and that all plumbing work and installations performed under the permit Issued for this application will be in comp!-• •with eli Pertinent provision o ,
Massachusetts State Plumbing Code' and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME V i eG TL io 5;I.ct4 LICENSE#3/39.$-3 SICKATURE
MP ❑ MGF 0 JP ErJGF❑ LPG]❑ CORPORATION�//�- ❑# PARTNERSHIP❑# LLC 0#
COMPANY NAME V4 iunr t�71VL6 �hY,.¢t'(ASc
/6 ADDRESS I� SAA6C)L y Lw-e
CITY NyAAFAJ IS p STATE ir/ 9 ZIP O O/ TEL
FAX CELL77 .83C,ol76 EMAIL lel QGiLroni 4 01104,04i1.• can
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ROUGH GAS INSPECTION NOTE THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �7L ` /n!/�
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FEE: $ PERMIT fl 41
PLAN REVIEW NOTES �j // �7
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