HomeMy WebLinkAboutG-14-262 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
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.ti- --NL-:_•=k CITY: YO-CnietidA ?tor 13 PERMIT r: 6�/�/-07��
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JOBSITE ADDRESS: C At`r L �1 OWNERS NAME -VA'G''� — Rea`
G OWNER ADDRESS: A'' IV- a FAX
TIDE OR OCCUPANCYTYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Q---/
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR Bsrnt 1 1 2 3 1 4 1 5 1 6 7 1 8 9 10 11 12 1 13 1 14
1 BOILER I 1 I I I I
BOOSTER 1 1 I I I I I
1 CONVERSION BURNER I I I I
COOK STOVE I I I I
DIRECT VENT HEATER
DRYER
FIREPLACE I I i _
FRYOLATOR I I
FURNACE I I
GENERATOR I /
1 GRILLE
INFRARED HEATER I I
LABORATORY COCK I I I
1 MAKEUP AIR UNIT I I I
1 OVEN I L
I POOL HEATER
ROOM/SPACE HEATER I I I -
1 ROOF TOP UNIT 1 I _
1 TEST
UNIT HEATER 1 I I 1
I UNVEJTED ROOM HEATER E I I 1 1 I
I WATER HEATER I I I I I 1
�V I I 1 I I I
INSURANCE COVERAGE
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G u, t ' r:bit' insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO ❑
�y i h0che ke•YES,please indicate the type of coverage by checking the appropriate box below.
\ sc9 �P� C� LIABILITY INSURANCE POLICY L2J OTHER TYPE INDEMNITY ❑ BOND 0
L Jj achus�etts GGeneraal LaCE ws and that my signature licensee
permit application n waives this requirve the insurance e nen requirede by Chapter 142 of the
es CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of tie 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 installations performed under the 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�i- at`'' ft(ccc/O LICENSE I3,2S( —�/ `�`
d _ ,p GNATURE
COMPANY NAME ?Se I 7 �''m/ e j c- ADDRESS: 9 I ..--May,...- //
CIN: (DA STATEM• ZIP: 483.36 FAX 6 ROU -3�0T
TEL: Sol 466 1204 cELL:for iW- V557 EMAIL:. 6 i edpkwi NI I NC d ✓c r 2&N. eye+
MASTERJOURNEYMAN❑ LP INSTALLER❑ CORPORATION Cf 3/6 t4 PARTNERSHIP❑! LLC❑= 1
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g IIIS PAGE FOR INSPECTOR USE ONLY YLNAL INSPECTION NOTES
Yes No ,
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
_ FEE: $ PERMIT 4 _ _
PLAN REVIEWNOTES _