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HomeMy WebLinkAboutG-14-924 Go _. L G 3Pryr- /y -0U4 )O ' e: ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY I/ocn.ck� flMADATE II—JS _-1`f PERMITt IVY- FoW JOBSITE ADDRESS L s 1 vcr ?K IAJlon OWNER'S NAME 1-11:Z-4-,rn e,en . . I G OWNER ADDRESS ITELI FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION: ►.w REPLACEMENT:® PLANS SUBMITTED: YES© NO C4 APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER R 20110.1n$1.00111.1.114011110111.001111.011. . BOOSTER �It` iiia CONVERSION BURNER II— '— dra - � a COOK STOVEiR j . DIRECT VENT HEATER t�� {S ; `� % _ DRYER �I orifi'_ — I r FIREPLACE �g S, i J # , FRYOLATOR :_— '_ � S S FURNACE — I I,, S GENERATOR GRILLE i T_ 1 . INFRARED HEATER I, • I 1 LABORATORY COCKSI puns sormsinc ._ MAKEUP AIR UNIT SrMintlinlirIS 1.1.011001 ;' , _ 2, OVEN a ea L :111WSINIS SIMINIMIXi .. POOL HEATER ` S. ASSIONIt ROOM I SPACE HEATER `— ' ------' ROOF TOP UNIT _nalallni TEST UNIT HEATE-.. ...e�a7 .�I . � 1 51. • e ,�'_ INSURANCE COVERAGE -• � • • ••Iley or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO Q I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER:lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement • CHECK ONE ONLY: OWNER 0 AGENT 0. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details end information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that ell plumbing work and installations performed under the permit Issued for this application will be In corn• .• :with all Pertinent provision o the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • PLUMBER-GASFITTER NAME ETIi_. I_"(�. LICENSE B I SIGNATURE ,l • f C, MP MGF0 JP® JGFD LPGI0 CORPORATION DI PARTNERSHIP[#CLLC®#r--E it COMPANY NAME: 1'' ry�$•$ l.� t..,. 1ADDRESS i, f 1 I • �r 1a CITY L.Y 41.t.Ctlrk.Fd \ S STATE MA 1ZIPa , ,aTELInt g fr' •' FAX 11111111111 CELL! EMAIL LR 0- • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR iUSE ONLY FINAL INSPECTION NOTES OU/,t QV- f7 L/-18-4L i Yes No ); C1-4 89/2-Y/64 "Vol a-t/ VIVA( THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 0 +.rT FEE: S PERMIT# PLAN REVIEW NOTES t ' I J