HomeMy WebLinkAboutG-12-547 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
LiCITY: y/ m07/ MA. DATE: • a/��//A PERMIT#C/275 'l
JOBSITE ADDRESS: if / Pi, iZtW 401 OWNER'S NAME:4Y/rnJ /45Ca#tc 'e
GOWNER ADDRESS: 6:4011/r- • TEL: V%- 94.007f FAX: •
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL Illy
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:& PLANS SUBMITTED: YES❑ NO 0
APPLIANCES? FLOOR Bsmt 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
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
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 Da NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY t5r. OTHER TYPE INDEMNITY 0 BOND ❑
•
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 will be in compliance with all Pertinent
provision of the Massachusetts State.Plumbing Code
e/and
/Chapter 142 of the General Laws. •
PLUMBER/GASFITTER NAME: ,/€cn /2 /572 LICENSE# 87,52. SIGNATURE
COMPANY NAME: /h'// M/,tt'vC ADDRESS: 99i 040 �') -7-a'7 i2",i
CITY: (J. Atm, �AM. STATE: ,04A• ZIP: 09660 FAX: 6772'"g '^
TEL: ,'5-0S--3if 9/0?7 CELL: EMAIL: /><-FY—/X /' 4-0CJ.e/t12o+ •n...aT
MASTER ra'JOURNEYMAN❑ LP INSTALLER 0 CORPORATION❑t c-ggv'3 PARTNERSHIP 0# LLC 0#
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: Y PERMIT I
PLAN REVIEW NOTES