HomeMy WebLinkAboutG-19-2385 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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rr• `I PERMIT# ir79' 10.015
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JOBSITE AD/DRESS 3'r Heir v a r cd S i- OWNER'S NAME moil /61'IC
GOWNER ADDRESS s A TELA i-to$S SL64FAy,
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Gx
PRINT
CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:[3 PLANS SUBMITTED: YES 0 NO 9'
APPLIANCES 1 FLOORS-+ BEM 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
GE /
GENEERATOR
GRILLE
Pl!
INFRARED HEATER `'
LABORATORY COCKSMAKEUP AIR UNIT 11$110.17.
1OVEN -POOL HEATER
ROOM f SPACE HEATER O`cr
ROOF TOP UNIT
TEST _. • - -.-
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 0 NO Et
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 LA/
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 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 compliance with all Pertinent rovi•i.• of the
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State Plumbing Code and Chapter 142 of the General Laws. !� a 76-1/45- if
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PLUMBER-GASFITTER NAME LICENSE# aa�ss SIG L-,,
MP❑ MGF 0 JP El JGF 0 LPG(0 CORPORATION 0# PARTNERSHIP 0 It LW 0#
COMPANY NAME 390- (('9r1 t ADDRESS
CITY 5 aryn STATE /'n4 ZIP 39 Monomay get TEL S°P•6 Os--544-6
FAX CELL $13b - 6es S6 r6 EMAIL /Z it
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑ �
FEE: $ PERMIT# /&/ //� t-
PLAN REVIEW NOTES o 7i2
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