HomeMy WebLinkAboutG-14-940 11 %' MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
y7CITY$ V�AVhl 9 MA DATE ttl,I PERMIT# v�1i` Q
JOBSITE ADDRESS �e2AbAYo. (Jr OWNERS NAME ICIYairlte._ y.2r
, 'G - OWNER ADDRESS TEL 5'0A4913169s_FAX 1
TYPEINT T OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PR
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑
APPLIANCES 7 `FLOORS-. BSM `" 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
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM(SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTEFDD ROOM HEATER,ig11 '
OTHER" /V0t
I APR 30 7I'!14
i I
P;777;II +1, ribnweir '‘n-..1t.NT I
r+ -- 1 INSURANCE COVERAGE �/
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES Cd NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COV GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
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 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application we Hue and accurate to the best of my ImaMedge
and that all plumping work and Installations performed under the permit Issued for this application will be In compliance with all °tenant provision of the
Massachusetts State Plumbing.Code and Chapter 142 of the General Laws.
R NAMEj �`
PLUMBER•GASFITTE
.ST'�PM� !� , Ems LICENSE# 1528 SIGNATURE
MP B"MGF 0 JP 0 JGF 0 LPG!0 CORPORATION 0 A PARTNERSHIP 0 It LLC❑it
COMPANY NAME 4.6Es✓A/f4C. ?cw,y a/nr6 417/44 ra'vb-7'ttCADDRESS ?o Sox 65(0
CITY 5A6Aill orC. STATE 1-14 Zip 025(o( TEL(SoP) 3I-7 - 94"80
FAX CELL(for)73'7-0.3/7 EMAIL Sit✓t t2 ¢zlgcwA44 rp ion k),,a Inc . cont
•
'LOUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
4
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMIT/
PLAN REVIEW NOTES