HomeMy WebLinkAboutG-14-184 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�, CITY: ya-r/iM-A
MA. &
DATE - 2l'/3 PF 17
PERMIT /—Ig7tl
JOBSITE ADDRESS: / et-hr boon"( AI- OWNER'S NAME fla'"c.-c. lR tally
OWNER ADDRESS: N• A/4 51-' TEL FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:E]' RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES? FLOOR Bsnt 11 I 2 I 3 4 51817 8 9 I' 10 11 112 1 13 I 14
BOILER I I I I I I II
BOOSTER
CONVERSION BURNER I I I I I I
COOK STOVE I I I 1I I
DIRECT VENT HEATER
DRYER I I
FIREPLACE I
FRYOLATOR I I I I
FURNACE / I I I_ I I I I I I
GENERATOR / I I I I _
GRILLE I I ,
INFRARED HEATER I I I I I I
LABORATORY COCK
MAKEUP AIR UNIT I I I
I
OVEN
POOL HEATER I I I
ROOM/SPACE HEATER I I I .
ROOF TOP UNIT I I I I
TEST 1I I
UNIT HEAT - �- I
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INSURANCE COVERAGE _/
Bhtiv t t .d•, ;.. . .rice policy or its substantial equivalent which meets the requirements of MGL Ch. YES L7 NO ❑
you have checked YES,please indicate the type of coverageerby checking the appropriate box below.
LIABILITY INSURANCE POLICY L/ 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 true and accurate to the best of my
Knowledge and that all plumbing work and insthllations performed under tie permit issued for this application will be in compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .
PLUMBERIGASFI I I tHNAME TWcry 61 CO-"65 LICENSE# f 3ZS' SIGNATURE
COMPANY NAME: PPO Biot f/v wbi 1n.c. ADDRESS: 9 S . //u n' .
CITY: az_c'u'cr STATE: Aka ZIP: 02330 FAX: 5t $16 32oq
alb'? tU 32o'4 CELL:aPr 856 Y5-St EMAIL' ralc1O6- pL.tkt%.y 1rc c Vc zc-". -"ct
MASTER❑-OURNEYMAN 0 LP INSTALLER 0 CORPORATION ET 3/6 q PARTNERSHIP 0# LW 0#
ROUGI[GA INSI'E I OIC TRIS I'AGE FOR INSI'ECIOR USE ONLY FINAL INSPECTION NOTES
Yes No
Tills APPLICATION SERVES AS TI IE PERMIT ❑ ❑
FEE: $ PERMIT I _
PLAN REVIEW NOTES
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