HomeMy WebLinkAboutBLDG-19-003099 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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to CITY c. 7YRAIOUi MA DATE II/I9l/f PERMIT# .10if
JOBSITE ADDRESS 100 MAYrrOQER 71 4A Cl OWNER'S NAME IONA BAUAS
OWNER ADDRESS SRMr TEL c9i74SI'810) FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 127
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CLEARLY NEW:Z RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO[�
APPLIANCES 1 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 elfli bC (I )
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT I � C „�, E
OVEN r
POOL HEATER
ROOM 1 SPACE HEATER I 'UV , ,
OROOF TOP UNIT .
v TEST _. F}LIILJINC-0'PA' , _
UNIT HEATER " —
tUNVENTED 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 plc❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L7 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
I hereby certify that all of the details and information I have submitted or entered regarding this application xe true . • -ccurate to the best of my knowledge
S• and that all plumbing work and Installations performed under the permit Issued for this application will bei compli.dwith all Pertinent provision of th-
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUME ASFITTER NAME LI ENSE#/5 NATURE
MP MGF 0 JP 0 JGF 0 LPG(0 CORPORATION DI n PARTNERSHIP 0# LLC 0#
COMPANY NAME PCCS OtFE pt.,..),46.c...../6 ADDRESS Po.. lea" nc
CITY c UENNrc STATE p1/1- ZIP 1 6c,0 TEL cor'grr't70
FAX CELL EMAIL ')
C
1070
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No •
//� //�� �� ///(A/ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
paili- („p / o FEE: $ PERMIT# PP///if` •
/71— � PLAN REVIEW NOTES `��'