HomeMy WebLinkAboutBLDG-17-002633 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESS LI 7 tunics St—E-0 cm pia- OWNER'S NAME
GOWNER ADDRESS 7C. SG«T/f 5r. Song Y4leericirtrEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL fgf_
PRINT
CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 2 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14
BOILER -
BOOSTER
CONVERSION BURNER
COOK STOVE I
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER _
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST I
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER I
OTHER
INSURANCE COVERAGE
I have a current Iiability_insurance policy or its substantial equivalent which meets the requirements of MOL Ch.142 YES ANO ❑
a I IF YOU CkIE D YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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LLI to 12 LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
> OWNER'i IN URANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massacse s General Laws,and that my signature on this permit application waives this requirement.
W CO :o I
o i z I CHECK ONE ONLY: OWNER 0 AGENT 0
W o !S I SIGNATURE OF OWNER OR AGENT
- I hereby'c&'rti 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
a ply4tubing work and installations performed under the permit issued for this application will be in compliance with all Pertinentti^ provision of the
Massachusett$State Plumbing Code and Chapter 142 of the General Laws. eeGe -«-�th7 C.G,si./r.r.
Z PLUMBER-GASFITTERNAME LICENSE# //1100 SIGNATURE
4-1 MP 15-4 MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION4-# -PARTNERSHIP 0# LLC 0#
COMPANY NAME EO curt-1X ()LWvvtf3tt-t5 +Rescrre46ADDRESS P.O. DOA. `s 1(
CITY Hoizr11 C1ttTK4-01 STATE wt4 ZIP 0zGS-o TEL 7?v-7s)-ne
FAX CELL EMAIL EDCmePLUM S0Z_P: 4tro'1any
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTE
Yes No W I7 O C�12� /1/7//C
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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