HomeMy WebLinkAboutBLDG-15-001748 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY ARAi sE_Di - j MA DATE: V2 O :PERMIT#I04- 5—ro/42/
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JOBSITE ADDRESS;Jc21- L T OWNER'S NAMEI---.Cal---4k.,---C-C---Z_
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OWNER ADDRESS ^ � 4� 416
TYPE OR _
OCCUPANCY TYPE COMMERCIAL,-1 EDUCATIONAL RESIDENTIAL j
PRINT
CLEARLY _
NEW:_ RENOVATION:1,j REPLACEMENT:Z PLANS SUBMITTED: YES[ ; NOL.,:
APPLIANCES-1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER - - - A .
BOOSTER "
CONVERSION BURNER €
• .P - GSC-_ - `- - - -�
COOK STOVE
I DIRECT VENT HEATER s _ 3 -
1 DRYER -a
FIREPLACE • - ilia _ -Y
FRYOLATOR �- .� 3 i
' FURNACE _ =+ .-
GENERATOR
GRILLE `t�
INFRARED HEATER -�
LABORATORY COCKSOa- 7 MS -"
MAKEUP AIR UNIT - -
OVENSlailajWili - _ ._. .
POOL HEATERfa= r= -
ROOM I SPACE HEATER
ROOF TOP UNIT a
TESTnI tititma _ .}--...
UNIT HEATER
W EQROOM;HEATE -i
WA ERHF�kTER '- "' llailli
OT. ER ' �F ! ^IIIIIIi
p�?_8.2 M ilal atil _--
MOWS, INIESINIMINIIIIMPISIIIIIIIIIIiallilit
. ._Duni r o r lir INSURANCE COVERAGE
I have aBy current li iliity insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YEW NO -
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND L
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 i AGENT
SIGNATIJ E OF OWNER OR AGENT
rd this application are true and accurate to the best of my knowledge
I hereby certify that all of the details and installations
performed
n I have submitted or enteredd regarding vaJ PPI
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit a eminent Provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,,� '1.�` � -{
PLUMBER-GASFITfER NAME ii-„M R At I,0Ci Og / �,{�LICENSE#J LL SIGNATURE _
MP MGF^- ' JP _ JGF_ • LPGI L+ CORPORATION,}#17l' I PARTNERSHIP i- -=ii— -- LLC]#`
COMPANY NAME ko n).Jw�ni !b{-NF-B-106.1 ADDRESS' ` i ).3 Lincc/ AL/C�-,_-...,-.._,...-.J
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STATE WO,. iZIPa)7eg2. -1TELI PK-5ff59 ---
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FAXS�l T! i�J CELLi . JEMAIL'_ Vu s, a 5:�.� _�
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S-- PERMITp-- — --- —
PLAN REVIEW NOTES