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Home My WebLink AboutG-19-3794 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK b �t CITY Yt7 0 4\ ' MA DATE / /ORA I ie PERMIT Y&D6"1?'00Rn 6/� a,&e L JOBSITE ADDRESS 021 S1`P.(zRlk. ' ' n�" OWNER'S��}}��NAME ©© ��JJDD G . OWNER ADDRESS al Slp2Ra y .TEC5 9gell /a FAX TYPE OR ,OCCUPANCY TYPE COMMERCIAL❑ UUEDUCATIONAL 0 RESIDENTIAL[a' PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑ APPLIANCES 1 FLOORS-• 851.4 1 2 3 4 5 6 T 8 9 13 11 12 13 14 BOILER F BOOSTER CONVERSION BURNER COOK STOVE , DIRECT VENT HEATER DRYER FIREPLACE . FRYOLATOR - - - FURNACE GENERATOR GRILLE INFRARED HEATER ! R F C, j I l : ii LABORATORY COCKS ` r MAKEUP AIR UNIT i ! ' '— — OVEN I 1 JEC b L71u POOL HEATER �) �� ROOM ISPACE HEATER �J/i EPA ct ROOF TOP UNIT I[!._ —=_ -- -- 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 [FIGO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILiTY INSURANCE POLICY tom-RAOTHER 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 ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted a'entered regarding this application are true and acarate to the best of my knowledge and that all plumbing work and installations performed under the permit issued forums application will be In compliareth all PRytinent of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �yjj/�JJ / � PLUMBER-GASFITTER NAME UCENSEY,6,FIa SIGNATURE MP IIMGF❑ JP❑// JGF 0 LPGI❑ CORPORATION❑1 PARTNERSHIP❑1 LLC❑1 COMPANY NAME ✓�6.7 l ,¢/t4inJ /74/1/ ADDRESS P 210 &'to7 0"' CITY LfA4 th I-C3U y STATE M A- ZIP e Af/C TEL www f- 7-1S--C-70Z2 FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 P1/114//—M FEE $ PERMIT# J 1Z4'v,w;�� 6 PLAN REVIEW NOTES C M e!