HomeMy WebLinkAboutG-19-436 1 • „re MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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N" CITY IA'tUtA/1 MA DATE 7-�/ f0 -O&7
JOBSITE ADDRESS r t b F24UC. /Sae-504,5FM• OWNERS NAME r ick-05
OWNER ADDRESS 2C) A'- /t b Iw 9_^ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL Er—
PRINT
CLEARLY NEW:21"---RENOVATION:0 REPLACEMENT:0 PLANS SUMMED: YES 0 NO 0
21"---
APPLIANCES 1. FLOORS—. BSM I 2 3 4 5 6 7 8 • 9 10 11 12 13 LiLi
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE I •
• DIRECT VENT HEATER
DRYER —
FIREPLACE I
FRYOLATOR
FURNACE
GENERATOR '
tGRILLE -
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
c.
k OVEN I - {
POOL HEATER s I JULn •RR `_
ROOM(SPACE HEATER
g ROOF TOP UNIT I L _
UNIT HEATER — --
UNVENTED ROOM HEATER —
J 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 alo ❑
11— I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
t LIABILITY INSURANCE POLICY BRAOTHER TYPE INDEMNITY 0 BOND 0
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° OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
t Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER 0 AGENT 0
J SIGNATURE OF OWNER OR AGENT
7-1+ 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
'j and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the
Q j Massachusetts State Plumbing Code and Chapterha142 of the((�General Laws. ����7
PLUMBER-GASFITTER NAME CM( fit 5 --IPC LICENSE#/3,2 6 ' SIGNATURE
MP 0 MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION l 3bSq PARTNERSSHIIP/❑# LLC 0#
COMPANY NAME Pk. U pI tM / r ie 7141•C• ADDRESS r Fel e_f e'( ��Gt Rd•
CITY n1/4/fri7STATTE� /44 n
ZIP c6o TEL 77 ' 773 9` d
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FAX CELLC+ V C� EMAIL
ROUGH GAS INSPECTION NOTES THIS. PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
� �j�S THIS APPLICATION SERVES AS THE PERMIT 0 0 NO /ex-- dTe
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�lQ f I U7-/ FEE: $ PERMIT# pvn/` rp�
PLAN REVIEW NOTES
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