HomeMy WebLinkAboutG-12-224 S ,.=r'_=
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_- CITY Ya
\i t I nth I, MA DATE/ I 70.-/g- 1/ ' PERMITIiC12)•21
GJOBSITE ADDRESS I Q/Gr//ZUCU/J�/ 7/ i 1 OWNERS NAME li cit 0/Ll�f(7j l��Zj/C� I
OWNER ADDRESS: I laze I Y/e4006�TCC' ( TEL' I 1 AX ( I
TPS OCCUP YTYPE COM CIAL 0 EDUCATIONAL 0 RESIDENTIAL
07
CLEARLY NEW: RENOVATION: '[REPLACEMENT:0
PLANS SUBMIT'T'ED: YES 0 NO i
FIXUUTRES 1 FLOOR-• Band 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BOLER
BOOSTER
CONVERSION BURNER
COOK STOVE hG t v C '�
DIRECT VENT HEATER f
DRYER
OC-
FIREPLACE X1 8 UAL
FRYOLATOR 1 p D
FURNACE I
au LIZ LH
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER /
•I have a current liability insurance INSURANCE COVERAGE
policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ■ NO 0
If you have checked YES please indicate the type ofeo by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMMTY 0 BOND 0
OWNERS INSURANCE WAIVER:I am aware that the licensee g the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application rafts this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
hereby certify that al of the detale and Information I have submitted(or entered)regarding this appfcadan are true and accurate to the best of
Knowledge and that all plumbing work and Installet ne perkrmed under the permit Issued for this application will be mpllance with al Pertinent
provision of the Massachusetts State Plumbing Codeja M Chapter 142 of the General Laws. p
PLUMBEWGASFITTER NAME: I(q's7 f elt/of I LICENSE l`ZIM/ S R��/ �� •
COMPANY NAME I -ro ['1 Ad I ADDRESS:I iiPAo /44'
CITY: Vhi y�� p� I
STATE-L`JLJ ZIP.167/6 n I FAX ( I
TEL:I5od- .9 tai/ I CELL:I f EMAIL: I
MASTER I2j JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 1:3# PARTNERSHiP❑puc p i
BELO P�FOR OFFICE U�-s E ONLA'
FINAL INSPECTION NOTES
R_ OUGH CAS INSPECT!O!'I NOTES
Y ❑
10El4 tc e,va�- S _ . , t
M r
/ l�12- 2�`�
Y � FEE: $l0' PERMIT.
PLAN REVIEW NOTES