HomeMy WebLinkAboutG-13-951 _I:~'\rte MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
e" ' CITY: MA. DATE: �7 ^/ `� 1 3 PERMIT# 2.-^/c9-767
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JOBSITE ADDRESS: f f 2-7 k-c3S 1/49"7 .•t 1CWNER'SNAh1E 3oSa. VA S// J/®
GOWNER ADDRESS: TEL 1 5°3-S�uu C5 5FAX:
TYPE OR OCCUPANCY TYPE: COMM CIAL 87 EDUCATIONAL 0 RESIDENTIAL 0
PRTNT
CLEARLY NEW:0 RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES1 FLOOR Bsmt 1 2 3 4 5 B I 7 8 I 9 10 11 1 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I �
DIRECT VENT HEATER
DRYER I _
FIREPLACE �
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER �
h (au LABORATORY COCK
MAKEUP AIR UNIT I �
OVEN
POOL HEATER
• ROOM/SPACE HEATER I
ROOF TOP UNIT
TEST �
UNIT HEATER
•11' ' UNVENTED ROOM HEATER
• W TER HEATER
t OVo_ A.
v INSURANCE COVERAGE
I 734*
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0
If you have checked YES,please indicate the type of covers a by checking the appropriate box below.
\� LIABILITY INSURANCE POLICY 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
p 1Massachusetts General Laws,and that my signature on this permit application waives this requirement
C7 CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
'M 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 installations performed under the permit issued for this application will bb compliance witt�aIIII P
neat
1 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. G%`✓, 2 �?`
V� PLUMBER/GASFITTERNAME: ?4Sc/// IL /!A'S-"-- LICENSE.# 36/6' SIGNATURE
COMPANY
NAME: j iki"-r- P J I ADDRESS: '335 $e-"°'4'✓u' -4, 12�
CITY': 2 6111003STATE: Mn • ZIP: 024-34 FAX: co F 5'43 62.31
TEL: Sor `S4L-62.31 EM r6T.. o/.GO^-r
i1 I. i 5 1I 1
MASTER 0 JOURNEYMAN LP INSTALLER❑ CORPORATION 0, PARTNERSH!p D # ac 0
;IA& b ?
r
ROUGII GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT
PLAN REVIEW NOTES
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