HomeMy WebLinkAboutBLDG-18-002902 f = MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
• %COW CITY f Armoct4 MA DATE 02/17 PERMIT# 6/8ca,2fa,Z.
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JOBSITE ADDRESS /6lv r/�LS�d.CPc y Rol OWNER'S NAME J-: 4` a/7 i A cis
GOWNER ADDRESS TELT 6/'2- 79n7 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL(9
PR NT �/
CLEARLY NEW:❑ RENOVATION: L� REPLACEMENT:❑ PLANS SUBMI i I EU: YES 0 NO 0
APPLIANCES 1 FLOORS—, BSM 1 2 3 4 5 6 7 8 9 4 10 • 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE J,
DIRECT VENT HEATER
DRYER / '
FIREPLACE
FRYOLATOR
FURNACE R E !
GENERATOR
GRILLE 13 20I7
' INFRARED HEATER 'tLABORATORY COCKS n Fi,�Iiyd�EV
MAKEUP AIR UNIT e _
OVEN '
•
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST ./. . . ..
UNIT HEATER _
INVENTED ROOM HEATER
WATER HEATER /
OTHER
INSURANCE COVERAGE
L I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142 YES -NO 0
i I IF YOU CFIECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
a • LIABILITY INSURANCE POLICY Le OTHER TYPE INDEMNITY 0 BOND 0
6 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
J SIGNATURE OF OWNER OR AGENT
TIN 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 1 all Pertinent of the
�� Massachusetts State Plumbing Code land Chapter 142 of the General Laws. (/J
PLUMBER-GASFITTER NAME ela€M) eoc,/4 LICENSE#23/76 SIGNATURE
MP 0 MGF❑ JP u JGFIAPGID CORPORATION❑# PARTNERSHIP 0 4t LLC 0#
COMPANY NAME Cook Mt nhp fi'acrf r ADDRESS 76 Kerry Dr.
CITY ,rp/'S/an h9///S STATEP14. ZIP 0.2.64/7 TEL rill'Q0'eon-
FAX CELL EMAIL
i2c4- 4q
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 5 "� /ie c /36
/ I w.I FEE: $ PERMIT# of //2(--/
G `%
FLAN REVIEW NOTES
Ratinifir
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