HomeMy WebLinkAboutBLDG-19-002266 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
WS.rob CITY ir-1ntct MA DATE Oct f 6 123 PERMIT#M4O6-J9'47266
JOBSITE ADDRESS 3 6,2 &tn4J L*A1,P er.^. OWNERS NAME ,tue.t_ ?2 P-itkm,)
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 FDUCATION,AL 0 RESIDENTIAL®--
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENTT PLANS SUBMITTED: YES 0 NO❑
APPLIANCES 2 FLOORS BEM • 1 2 3 1 5 6 7 8 9 10 11 12 13 14
BOILER —
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER 4
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR _
GRILLE / _
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT E C E VE �T
OVEN .-_
POOL HEATER I ,
ROOM SPACE HEATER i�
ROOF TOP UNIT r- ;;
TEST stn U'I enT iS
UNIT 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 MGL.Ch.142 YES,f10 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a. OTHER TYPE INDEMNITY 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.
CHECK ONE ONLY: 0 ,. ' 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
riz I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc -te to the b:st of my fr- -.ge
and that all plumbing work and Installations performed under the permit Issued for this application w_' • •• amp•. ce ' al - -'•ei rovisio . e
Li) Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSI # 17 t97 SIGNATURE
MP 0 MGF❑ JPag-•-JGF❑ LPG'0 CORPORATION 0# • - - 'HIP 0# LLC 0#
COMPANY NAME �tp , 1,L/_c)LC.f q 1 ADDRESS L 9/ Mg Sr
CITY IA'At � L STATE S ZIP 026 Ccr TEL see 77G /s to
FAX CELL EMAIL
RCTHIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Ye5 No
THIS APPLICATION SERVES AS THE PERMIT 0 0 .
FEE: $ PERMIT# - / i/ `,
PLAN REVIEW NOTES 01/ i
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