HomeMy WebLinkAboutG-14-259 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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' CITY: ,ct9Ttt/J �J g�/ nn/ DATE 1
`' '� JOBSI DRESS:X. ! Ur1 f") 1 ''1�'^vOWNER'S NAME J
GOVVNERADDRESS: TEU FAX
TYPE OR OCCUPANCY TYPE: COMM CIAL❑ EDUCATIONAL 0 RESIDENTIAL 1-1-
PRINT
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CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
CO APPLIANCES1 FLOOR 1 Bsmt 1 1 I 2 I 3 4 1 5 1 6 1 7 1 8 9 1 10 11 1 12 1 13 1 14
BOILER I I 1 I I 1 I I I I
BOOSTER I I I 1 I I I
CONVERSION BURNER I I I —
COOK STOVE 1 I I I . 1 1 I _
DIRECT VENT HEATER I I I
DRYER I I I
FIREPLACE / 7 I I I I I
FRYOLATOR I 1 I I • I I
FURNACE I 1 I I I I I -
GENERATOR I 1
GRILLE
INFRARED HEATER
I I I _
LABORATORY COCK I , ( J ( 11 r I r ri ! �1 r• I I 1
MAKEUP AIR UNIT I "1I 1'7_ 1 I
OVEN I I I
POOL HEATER c p
ROOM/SPACE HEA ILK `� r 2 20,3 , I I
1 ROOF TOP UNIT I I I 1�i�B pr r _ I
TEST I / I I —I I d / c, "'Ni
UNIT HEATER I , +_ 77( 00 1
UUNVENfED ROOM HEATER I I I I 1 I 1
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INSURANCE COVERAGE �
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES fJ N0 0
If you have checked please indicate the type of covera7 by checking the appropriate box below.
LIABILITY INSURANCE POLJCYie. 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 a . -te to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this epplicatio • be in •%lance with all Pertinent
provision of the Massachusetts Sr,a •1u •ing Code-nd Chapter 142 of the General Laws. n 1r
PLUMBER/GASFITT i'NAME I Ii • s ' .. LICENSE j�/V/02 SIGNATURE
COMPANY NAME: 4/�.ql d i / ' ht ADDRESS: �rI nW/,4/ I
CIN: _ii P STATE:414- ZIP:�",(.i7Lt7j2 FAX�L ^ , �--
TEL ' ' i J )76? cal: amt.:1IQ//Pila 57(011P‘ t fl eOn1
MASTER/2/JOURNEYMAN❑ LP INSTALLER 0 CORPORATION a/ PARTNERSHIP 0# LLC 0
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ROUGE( AS
lNSl'ECTlON NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
(ewe- <e4.cf /1<f 9.�Yg Yes No
TI IIS APPLICATION SERVES AS TIIE PERMIT ❑ ❑
FEE: $ PERMIT II _
)'LAN REVIEW NOTES -
•
Y