HomeMy WebLinkAboutG-14-344 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY: tttwsvt / Aa Mk DATE i°Ji c/re) PERMIT Zdy 3yy
0� JOBSITE ADDRESS: 3 4 reA Z i vi y (t( OWNER'S NAME m At ✓f C5 s t%e. A
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1 G OWNER ADDRESS: 39 Fa r�vy/ 110
)I TEL enII" 7?Z-3C' FF-An
TirPE OR OCCUPANCY TYPE COMMERC41L❑ EDUCATIONAL 0 RESIDENTIALE
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CLEARLY NEW:el RENOVATION:❑ REPLACEMENT:❑ PLANS SUBIvMfrTED: YES 0 NO❑
APPLIANCES1 FLOOR I Bsnt 11 I 2 3 4 1 5 6 1 7 8 1 9 1 10 1 11 12 1 13 1 14 ,
BOILER I I I I
BOOSTER I I I I �I �� 1
' • CONVERSION BURNER I ✓I I 1 -I
COOK STOVE 1 /I I 1
DIRECT VENT HEATER / 1 C)
FIREPLACERYER
F 1 �� I� 17,, �
FRYOLATOR I I 1 /� %� 1 1
FURNACE • 1� 1
GENERATOR i I /.....(5 ,5s. I
GRILLE
INFRARED LABORATORY
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MAKEUP AIR UNI .:10I' (.I \ 1 ""-C'
OVEN (Of
1 ROOL /SPAC
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER-� , I 1
UNVENTED ROOMHEATER 1 I
WATER HEA itV 1 1
I I I
\ 1 moi\ INSURANCE COVERAGE
tori e a Curren iabitjtyins-mance polity or its substantial equivalent which meets the requiremens of MGL Ch 142 YES 2rNO 0
\I`yo tiav i jd YES,please indicate the type of coverage by checking the appropriate box below.
e+ LIABILITY INSURANCE POIJCY 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 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 co rice with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBS /GASFI1 ltHNAME a ZJv Cls LICENSE4 31366 S NA RE
COMPANY NAME: B Sc r)). 145 Sr4 a ADDRESS: ' -BactO A) goisse RD
CITY: Cath-La Vh STATE: AA- LP: 0 RG 4 FAX
TEL: CELL Svc 737-7 9sl am":
MASTER❑ JOURNEYMAN a LP INSTALLER❑ CORPORATION❑4 PARTNERSHIP❑r LLC❑g
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OUG1I GA LN51'E O r1111S PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
fri /oe cDt flM /4 it /5 Yes 'No
THIS APPLICATION SERVES AS TI IE PERMIT 0 0
FEE: $ PERMIT I
PLAN REVIEW NOTES