HomeMy WebLinkAboutBLDP-19-002745 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
W. CITY:4.arr,s,�C_44 `I� 61A DA / S PERMIT#`49179-OOg793-
JOBSITEADDRESS: 02-r Cretr m,A Co&Ie OWNER'S NAME: f7A'r`'h.nn ketwdy
GOWNER ADDRESS' t/.�ias'f/.pnrrninn e.:/ill 3X)73,rWFAX: /
AOR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENT
CLEARLY NEW RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 N01D)
APPLIANCESI FLOOR-. Bart 1 2 3 4 6 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
' _COOKKSTOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
.. awl
GENER TOR /'J'� C d
INFRARED HEATER
G Gj
LABORATORY COCK , %_.'/
MAKEUP AIR UNIT \ �� (1 F ri°
O OVEN lri 1
,Z3 POOL HEATER 'r,'
ROOM!SPACE HEATER o.>C.1 • 1 ‘...--cave-
.✓" PP _
J ROOF TOP UNIT ,,c�%��/��
t TEST
UNIT HEATER
Cij UNVENTED ROOM HEATER
WATER HEATER -
INSURANCE COVERAGE
I have a currant liability Insurance policy or its substantial equivalent which meets the requirements of NGL Ch 142 YES 0 NOW
If you have checked,please Indicate the type of coverage bydwcking the appropriate box below.
UABIUTYINSURANCE POUCY 0 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee goes not have the insurance coverage required by Chapter 142 of the
Masseclusdts General Laws, hat my signature on permit application Naives this requirement
)0 . lK%1••A-.�.SJ.S.t CHECK ONE ONLY: OWNERS AGENT 0
•
SIGNATURE 0 OWNER OR AGENT
herebyoNSfy that all of the details and hfannadon I have submitted(or entered)regerduig this appicationare true and accurate to the best of my
Knowledge and that all plumbing work and Metallederts pertained under the penult Issued for tis applicator will be In coinpfarsewith a l Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 1421LIC
( the General Laws. .+Z�, a.,PLUMBEUGASFRm�'v
TFRNAME: TiOwed .)in.,./!Ki ENSE//1/T7U7/8 Act,
SIGNATURE
0 COMPANY NAME: ri ie e //IA( k-,C P/v"`I G r),4 ADDRESS'X G=-/(Pen bona/. Cr rc/e
CITY; yi r/s+ctrl2!pre r STATE: Ali+ ZIP:4�C7•-C FAX;
TEL: CELL; 77999z/3s93 EMAIL' z ?wefr7,11,./nwrl<.i grAell . Cein
MASTEtj`E JOURNEYMAAJ8) LP INSTALLER 0 CORPORATION I:1# PARTNERSHIP 0# LW 0 n
En14/1, ADDiZ ss:
BOUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY 7INAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERWHT#
•
•
•
(26 „e6zok (or ok(
Kw/4
me(4_ ? ai-fr• do*