HomeMy WebLinkAboutG-14-002 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: MA DATE: t• 9 / 3 PERMITS (7/71402
/
JOBSITE RESS: 3 CaIfreit 6-1 OWNER'S NAME Am i_.1� .•-•
G OWNERADDRESS:_p TEL .Q9 et. 2f 31 is FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[(�
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[" PLANS SUBMITTED: YES 0 NO 0
APPLIANCES1 FLOOR Bsmt 1 2 3 I 4 5 6 I 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
Co INFRARED HEATER
;O• LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT CR C
TEST .} &b`7
UNIT HEATER H 28 2Q'3
UNVENTED ROOM HEATER ��J(J
WATER HEATER V
ILC INC;U TAR-
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L'NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY LIQ 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 0 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 v' e in ompliance 9ti all erfinent
provision of the Massachusetts State Plumbing Code and Chapter 1428of the General Laws. a
PLUMBER/GASFITTERNAME: JO/></1/ D P6t&R S LICENSE# /OC_sO SIGNAT RE
COMPANY NAME:
f 613.R.5.- PL 4 I /T T1L)ADDRESS: 35- 9 p
CITY: g,��y� �' / STATE: / ZIP: 602-1$ q Y FAX
TEL: (0 S7•qv c 03 ILL CELL col-4 q 9 -3/L 9 EMAIL: •
MASTER EJOURNEYMAN❑ LP INSTALLER 0 CORPORATION 0 if; PARTNERSHIP 0 r LLC❑if
L/P{�
ROUGE!GAS INSPECTION NOTES THIS PAGE POR INSPECTOR USE ONLY FINAL INSPECTION NOTES
f eelf 649 c/t 4/n1 ,.///0 Yes No J•i c//r G/2/ft low
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
rttigra7 Cr-0,400/9 7/1"-if
/749-40 CO 1-- Canute- FEE: S ' .. ' PERMITI<
pVnuke& 42/f9 tat PLAN REVIEW NOTES
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