HomeMy WebLinkAboutBLDG-17-005775 L � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
' CITY YC r.� o k 7 MA DATE 5/5 /7 7 PERMIT# /31-067'/7-00 r97 r
JOBSITE ADDRESS Z- f-( if i✓1 i S T OWNERS NAME
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 1:1-------
PRINT
CLEARLY NEW: RENOVATION: 0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 7 FLOORS-' BSM 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 I
GENERATOR
GRILLE
' INFRARED HEATER
LABORATORY COCKS •
'
MAKEUP AIR UNIT
OVEN
POOL HEATER I P:,,,,,
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ROOM I SPACE HEATER T 7 T -•_:
ROOF TOP UNIT ,7...L.
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TEST L . . . . . .- f a 't -- --ime t --
UNIT
ER 7411 n .V
UNVENTED ROOM HEATER ( V
WATER HEATER t \.„ LEPq _ J
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OTHER 1Mt
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKINGTHE.APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNERS 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
3 SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and informafron I have submitted or entered regarding this application are true and accurate to the best of my knowledge
--• and that alul plumbing g work and Installations performedptenunder the ner l Laws.issued for this application will be in cornnriaP vision of the
Massachusetts State Plumbing Code and Chapter 142 of theGLzneral
PLUMBER-GASFITTER NAMEtrem J/0c•r c 3-e if LICENSE#-306 ca' SIGNATURE
MP 0 MGF 0 JP GiGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME f0r•oSY6f.- pic..,,.-, 4 ; ' !}
ADDRESS �03 LA St'
CITYyG i.,a,_., /I /lai7�—• STATE PI A ZIP 071'7 r TEL
FAX / CE Sdk- 9 Z'z- Ilam E-MAIL
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e G ;_a _ SPE O► ► THIS PAGE FOR INSPECTOR USE ONLY
FINAL INSPECTION NOTES
Yes No
(Pb I 1- THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /!^ /� nj //�/�pFEE: $ PERMIT# rP4/ V/ ' O
/let/ � PLAN REVIEW NOTES ` ^ /r 477
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