HomeMy WebLinkAboutBLDG-19-002685 •
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+a a�� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY MA DATE /u r figb79-od..:?la$S-
JOBSITE ADDRESS 2 I `4i1-4t ' S Les, OWNERS NAME L any
OWNER ADDRESS TEL FAX
TYPE OP. OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALLO�
PRINT
CLEARLY (JEW:0 RENOVATION: 0 REPLACEMENT:Er PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER •
DRYER
FIREPLACE
FRYOLATOR -
FURNACE
GENERATOR
GRILLE
INFRARED HEATER 1
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST - --
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE IIJDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
J CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
14‘ I hereby certify that all of the details and information I have submitted or entered regarding this application are t accurate to the b-s 'f my knowledge
`- and that all plumbing work and Installations performed under the permit issued for this application will be In c„ - t 1ail Pe. " erIvIsi.n of the
Massachusetts State Plumbing Code and Chapter 142 of he General Laws.
PLUMBER-GASFITTER NAAME6 A a rd "c LICENSE# 3 3 D - SIGN•TORE
MP 0 MGF❑ JP 1:21-GF// 0 LPGI
0 CORPORATION❑it PARTNERSHIP 0# A �/�LL/C❑#
COMPANYYNAME /`X L A fl,' �J ADDRESS /0a� &v'� ✓A'ho4 R
CITY /`7u/-urb� / STATE4 /T ZIP 0 91-•647 r /� TEL c0$"rJ"fc,-- GC//7
FAX CELL EMAIL C%4 r-1W 14-06 G e 6-mt,7
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 t�� �„� /) T" v 6A
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PEE: $ PERMIT �!/l/
PLAN REVIEW NOTES 0/z
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