HomeMy WebLinkAboutG-14-049 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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Ste CITY: W MA DATE 7/2-?-// 3PERMIT# C/// r/
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JOBSITEADORES :7 +cJ�—if D-t OWNER'S NAME ,45);2441"
GOWNER ADDRESS: TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 132--
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CLEARLY NEW:El RENOVATION:❑ ,4
REPLACEMENT:❑ ,e yrevtf 17 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR-. I Bsmt 1 1 1 2 3 4 5 6 1 7 8 1 9 1 10 1 11 112 13 I 14
BOILER
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BOOSTER N I I I I
CONVERSION BURNER I 1
COOK STOVE r f--
DIRECT VENT HEATER__. _ 11 I I I )
DRYER in, ' I I
FIREPLACE I . rI I 1 I I
FRYOLATOR I "" : 1 f r1 I I
FURNACE . . ckt V it I I
-C GENERATOR I 'l
GRILLE I •' —.11 I I l
INFRARED HEATER
LABORATORY COCK 1. _. - I I I I I
MAKEUP AIR UNIT ' 1
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT I
TEST
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER I I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 19' I�0 ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ 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: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTERNAME Jr6
on HN D. P R.S LICENSE# /6930 /Op�QSIIGNATU'^RE
COMPANY NAME: l �.'.r�. I), d- / ADDRESS: 3 5 2—+-� / Ef
CITY: '.-B-1.2-2 Lt / STATE ZIP: 0''I U '.f FAX -- -
TEL 50 ' ' ''177 -031/.2_ CELL: fa? -L 3 /G 5 EMAIL
MASTER Lf1 uuURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP 0# LLC❑
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ROUGE!GAS INSPECTION NOTES T11IS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No l=Cr✓YJti at 'h9 l/.2.4
THIS APPLICATION SERVES AS TIIE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES