HomeMy WebLinkAboutG-12-363 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
l = CITY I Yartnoufh
I, MA DATE
PERMITrG —363
G— JOBSITEADDRESS I105'C /'r.°pN C f^ 1 OWNERS NAME *
OWNER ADDRESS: I 4r w. n �l v
TYPE OR JTELI760 — 39 3/ I FAXI
/
PRINT OCCUPANCYTYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0
PLANS SUBMITTED: YES 0 NO 0
FIXUTRES l FLOOR—, Bamt 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE Gct.s La /
FRYOLATOR —I
FURNACE
GENERATOR
GRILLE —
LABORATORY COCKS
MAKEUP AIR UNR
OVEN
POOLHEATER
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
TERTEDROOMHFA
W
WATER P.ATEA'n te
Ihavea . I r INSURANCE COVERAGE
H(liability irnsurance polltfor Rs substantial equivalent which meets the requirement of MGL Ch.142 YE NO
If you have checked yES,please indicate the type of coverage by checking the appropriate box below. 0
LIABILITY INSURANCE POUCY{3 OTHER TYPE INDEMNITY 0 BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee0
Massachusetts General Laws,and that my signature on this permit thein mists this required 142 of the
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that al of the details and Information I have submitted(or entered)regarding this application are hue and accurate to the beat of my
Knowledge and that all plumbing work and batatath ns performed under the emit Issued for this application will be Inco
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. mpilance with al Pertinent
PLUMBER/GASFRTERNAME: lac)! CIct ph' I LICENSE/412thGM RE
COMPANY NAME IPS IKeer;ti ?Iv w b _ ADD ( t/2 '>�ivr
ADDRESS: h a<l Lce
CfTY: 4 r I STATE lnha VP:I D 3/ I FAX I
TEL:Is-aB Gra- ICELL:I 1 EMNL: I
MASTER 0 JOURNEYMANia LP INSTALLER 0 CORPORATION 0 ft PARTNERSHIP 0#=311.0 0 a
ROUGH CAS INSPECTION NOTES BETON FOA OFFIC
F nsx ONLY ANAL INSPECTION NOTES
Yes No
FEE: $_ _ PW&I_______
MainIEW NOTES
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