HomeMy WebLinkAboutG-14-039 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: y(AQYhC\0\-V !
MA DATE: -s 6-
`'' PERMIT# I�/y- 09
(('''tt JOBSITE ADDRESS:3(n� &r ect i- Ts(&'n OWNERS NAME 1)1 [ co 22-1'
�J OWNER ADDRESS: TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL ID EDUCATIONAL 0 RESIDENTIALyQ
PRINT '\
CLEARLY NEW;. RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR-+ I Bsmt 1 1 2 3 [ 4 5 6 1 7 8 9 10 11 1 12 13 1 14
BOILER 1 1
BOOSTER
CONVERSION BURNER I 1 1
COOK STOVE
DIRECT VENT HEATER 1
DRYER 1 1 /
FIREPLACE 1
FRYOLATOR Irr
_
FURNACE
H
GENERATOR � _
GRILLE
INFRARED HEATER 1
LABORATORY COCK 1
MAKEUP AIR UNIT 1
OVEN
POOL HEATER
ROOM/SPACE HEATER I
I ROOF TOP UNIT
TEST
UNIT HEATER � 1
UNVENTED ROOM HEATER -
WATER HEATER
INSURANCE COVERAGE ,,�r ""''
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES. .LLO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this applicatio rill be in co Ilan th all Pertinent
provision of the Massachusetts umbin Code
)a`d Chapter 142 of the General Laws.. W�
PLUMBER/GASF NAME\ te_(0 LICENSE tt 1 °) SIGNATURE
COMPANY NAME J \S Q ( VL✓\t-7 Y ADDRESS: ' SloC6 '
bu`
CTf uJ : STAT : ADI ZIP: 4)G 1/4-6- FAX
TEL
SIL 995 J GELL'777—5c" 552_ EMAIL:
MASTER 0 JOURNEYMANaNLE INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# `" " LC 0#
���— JUL 16 2013
kL 3.aoy 24;50 u.7-
ROUGH GAS INSPECTION NOTES TillS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES _
ea - G _O!C G/aV 7/17//i Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT
PLAN REVIEW NOTES