HomeMy WebLinkAboutBLDG-19-003274 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
c o y #13-121,-/9-ee. %/
�� , CITY *in o�n / MA DATE !/ oZ F�a 0 � O° PERMIT/�
JOBSITE ADDRESS 1--C orpifriz. ✓ 5704,7/e y ?ct' OWNER'S NAME(1)57.-71/A) .44/1''
GOWNER ADDRESS / TEISOP 3(,0 774/ ' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL g----
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:IS-- PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS- SSM 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
LABORATORY COCKS _
MAKEUP AIR UNIT r E C E I V E C`
OVEN r (
POOL HEATER
ROOM(SPACE HEATER NUV 2 8 ZUl�
ROOF TOP UNITLJ
TEST _.._..
._ ._ . ._ . _ _ _ _..._ __. _ - BULllJ r.136E PJ+RTMF[LT
UNIT HEATER dr __
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 [B1O 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ElOTHER 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 ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate t e best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In 'fiance with • I PPerurtiinnknt pro.slon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. lir
PLUMBER-GASFITTER NAME h,,,Da✓7y LICENSE# a39Fa ��
y!` SIGNATURE
MP 0 MGF 0 JP-IGF 0 LPGI 0 r, C PORATION❑# � 6/2-1,C1PARTNERSSHIP 0# LLC❑#
COMPANY NA /t7/ O�vm1/.7 r//rC ADDRESS? (TtL1 L;
CITY e e✓le" STATEnAi ZIP Det ri 3 / TTanV;2-F °YP3 •
FAX CELL r/4 7737?7 EMAIL Cie/vin Ley G (Lit('y.4: die'r
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERT1ff 0 0 9 J2,.� 01*' -�p
FEE: $ PERMIT# pun- VteT(
PLAN REVIEW NOTES %crilin 64
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