HomeMy WebLinkAboutG-18-6556 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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4FC! f. CITY Snul ti $4MOJTt& MA DATE 511111 C3 PERMIT#SDb Vr'°G 3
JOBSITEADDRESS 4.0- ORcMU.! SD.+.1Lv'( ith. OWNERS NAME (',A.i-6- KUC)SeN
GOWNER ADDRESS TEL c)2-34P,-CIO(e1 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL'
PRINT
CLEARLY NEW:❑ RENOVATION:el REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO.21.--
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER I.
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM/SPACE HEATER 'v r
ROOF TOP UNIT
TEST
UNIT HEATER MAY am
UNVENTED ROOM HEATER
WATER HEATER f a IL'' P. r.
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES,'NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 12r 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 ❑ AGENT 0
- SIGNATURE OF OWNER OR AGENT
I 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 be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
�J PLU_MBER•GASFITTER NAME No(-Witt._ vL'Ac) .1ada-+ LICENSE# (5493 SIGNATURE
MP E M�GF 0 JP 0 JGF 0 LPGI❑ CORPORATION 0# PARTNERSHIP❑# LLC❑#
COMPANY NAME & Ei MDE PWN6t4C3 a kPhT10-3(.1 ADDRESS 137 GHair4 SAAU-ILA•
CITY S. Vk1tMkrrt1 STATE IMA- ZIP 32449 TEL TN-lit( -I1?91-J
FAX CELL EMAIL osiletAtotoLumrs46,P-`&t+400.COJP\
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 rer/n/ f
643 O c-- • FEE: $ PERMIT# 0,-C
/e/// r PLAN REVIEW NOTES l