HomeMy WebLinkAboutG-13-117 •r I _� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
VIM CITY IfIWi11 MA DATE g.Ib'12 PERMIT# b/3 - I�7
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G JOBSITE ADDRESS II Wub t i ILn• OWNER'S NAME PAF'IC I k Ib YIpS0
OWNER ADDRESS II W(IIJM In. TEL 1g1'L41'gSbc FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL''
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT, PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER I
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER •
DRYER
FIREPLACE
FRYOLATOR
FURNACE • RECEIVED
GENERATOR
GRILLE
INFRARED HEATER AUG 14 20}2
LABORATORY COCKS
MAKEUP AIR UNIT RI III i
air
OVEN By
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POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES algEl
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ 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 ❑
SIGNATURE OF OWNER OR AGENT
I hereby catty that all of the details and information I have submitted or entered regarding this application are true and accu to to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian 4 •0vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-G ER NAME #�� • -S
LICENSE#./..570. SIGNATURE
MP MGF❑ JSP❑ JGF1❑ LPG]❑ CORPORATION LTJ VS'S PARTr.rHIP❑# LLC❑#
COMPANY NAME 2.1U -t S &SI [Jtitiq ADDRESS 5/ Willies fit&
CITY cl- YakaLlnla STATE n'&&4 - ZIP ( (u6kifr -� TEL feSc5�-6?0r
\. FAX CELL-3r'O-5277 EMAIL volestd4 slwGtaahnj Cct1Mj , Gat?
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES