HomeMy WebLinkAboutG-13-891 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY: MA. DATE:3"??t PERMIT 6)3-89
JOBSITE ADDRESS: 1)3 •(AA( -PA/ OWNER'S NAME: Itdt z r2betr,
GOWNER ADDRESS: TEL: FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PUNT
CLEARLY NEW:0 RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR Bsmt 1 I 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
GENERATOR
GRILLE
INFRARED HEATER I _
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER _
ROOM/SPACE HEATER
ROOF TOP UNIT �
TEST
UNIT HEATER I
UNVENTED ROOM HEATER _ _
WATER HEATER ,
tO ./
Vat INSURANCE COVERAGE ,�. /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L�J'NU 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY t 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 accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application in complip/�tce th all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTER AME: / '/WL t�J LICENSE# (e3j / SIGNATURE
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COMPANY NAME: r�`(Z2.Ck7 rL ADDRESS: 2-4- ba-Cacn.cC--I'3 �7Jr/S �4�
CITY: CLt r Cil STATE: ZIP:Ca-6g 5 FAX:
TEL: CELL:5�T L '"te44C EMAIL: FLA— r • r Si n k'd Af, I, UQ(
MASTER OURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTN RSHIP❑# LLG #
HART-7E073
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL
.AL INSPECTION NOTES
Yes No r/�J — >r t 44'
THIS APPLICATION SERVES AS THE PERMIT ❑ 0 9
FEE: $ PERMIT /�,/
PLAN REVIEW NOTES
•
l:Y
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