HomeMy WebLinkAboutG-14-417 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
•. .+ i CITY: ye/24m7- MA. DATE /O- /-2eiL3 PERMIT# (7/1/'Se
JOBSITEADDRESS: /551 Dl4h'- '5-171?) OWNERS NAME . 73CIt IW) 7i7
G OWNER ADDRESS: /3 c/I'1 fit �2%�i(p� TELtJO•. 4'E. O/42FAx
W\O POR OCCUPANCY TYPE COMMERCIAL[{ EDUCATIONAL 0 RESIDENTIAL 0
RIN
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR I Bsmt 11 12 13 4 1 5 6 1 7 1 8 9 110 1 11 1 12 I 13 I 14
BOILER I I 1 I I � I
BOOSTERI � I i I I I
CONVERSION BURNER I I I I
COOK STOVE
I� DIRECT VENT HEATER I / I I
DRYER I I I
FIREPLACE I I I I I
FRYOLATOR
FURNACE 1 I I 1 • I I I I
GENERATOR I I
GRILLE I I I
INFRARED HEATER I I I I
LABORATORY COCK I I I I
MAKEUP AIR UNIT �
OVEN
POOL HEATER I • I
ROOM/SPACE HEATER I 4_.1 .
I ROOF TOP UNIT I I 1
ITESl
UNIT HEATER
I
UN'VENTED ROOM HEATER / I I I _
WATER HEATER I / I I
INSURANCE COVERAGE LLL--_���
I have a current liability insurance policyequivalentor its substantial which meets the requirements of MGL Ch.142 YES NO 0
If you have checked YES please indicate the type of coverage checking the appropriate box below.
CI z LLABII.TTY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
W Cb. CW NL 'S NSURANCE WAIVER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
it$assA hvetts General Laws,and that my signature on this permit application waives this requirement
W M ;�y CHECK ONE ONLY: OWNER 0 AGENT 0
V �4U S1G v OF OWNER OR AGENT
. �'
Ce hereg -.- y that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowleg@ and that all plumbing work and installations performed under the permit issued for this applica on will be in co ria with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l
PLUMBERIGASFI I ICH NAME: Zb4'561007-19- UCENSE# ¢t.° S7 RE
COMPANY NAME -TSS CoA ry
S320 !l/ mw
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CITY; A/ SThe STATEkf ZIP: 4,263) FAX-508'cY .
AY 8'C1/ .474'6
TEL: 99-/i- 22-1j4,--cELL:9 q 772-nQri iAIL ci z @%rvmy e$r7
MASTER JOURNEYMAN 0 LP INSTALLER 0 CORPORATION ac/320 PARTNERSFUP 0# LC 0#
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MGT GA IN. ' r ".1 e i . r,• MS I'AGE ant IN$YECPO1l USE ONLY 'ANAL INSPECTION NOTES
RGA Co/� On at/ Yos No
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THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
THIS
FEE: $ PERMIT
}'LAN REVIEW NOTES
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