HomeMy WebLinkAboutG-13-275 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY I Yamauth
I MA. DATE I j PERMrr# b/3 -o77r
JOBSITE ADDRESS I (61771/(' /i/ I OWNER'S NAME�llp///,//i6V
G OWNER ADDRESS: I� P `4/,��V72/l�IJ/I T� 1 FAX
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YPE OR OCCUPAN TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL.2
CLEARLY NEW RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NQ0/
FIXUTRES 1 FLOOR—, emit 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE r\
GENERATOR r i
GRILLE
LABORATORY COCKS I MT
MAKEUP AIR UNITOVEN I L.. XT �$ Thi
POOL HEATER i Naf rgar:
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
• INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0
If you have checked its please indicate the type of cover,by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I ant 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 applicationthis
SIGNATURE OF OWNER OR AGENT ent.
CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that ail 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 installation performed under the permit Issued for this application will be In mptlance with all Pertinent
provision of the Massachusetts State Plumbing Code Chapter 142 of the General Laws.
PLUMBERIGASFITTER NAME:r/ � // �v v /�/l�
LICENSE# /� � S G
COMPANY NAME I6 &3/ �tef / j ADDRESS: /���&W a.y/4
CITY: vohleZ%'2, I STATE. ZIP: 0,47fr I FAX: I
TEL[4)7, 0/0-0)711 CEI:I I EMAIL I
MASTS' i JOURNEYMAN❑ LP INSTALLER 0 CORPORATION 0#lIPARTNERSHIP 0#r-SIC❑#0
ROUGH GAS INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
jP/C/1 GA-5 ox Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT S
PLAN REVIEW NOTES