HomeMy WebLinkAboutBLDG-15-001671 oFfcgpe
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
if=` ' tnt r ae..,Owti, Po"1' MA. DATE: IC? SS I9 PERMIT#/,/S=Oo/4 7/
JOBSITE ADDRESS: D.I/ Cain e-lot- OWNER'S NAME Zo L wi�S
GOWNER ADDRESS: TEL: _,<22r9 CO// 'IFAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL 0 RESIDENTIALar
PRINT
CLEARLY NEW:0 RENOVATION:Nit REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NOS'
APPLIANCESZ FLOOR-. Bsmt 1 2 3 4 5 6 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 COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
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k UNVENTEDROOM#iEAtES
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w INSURANCE COVERAGE
=1havka t78ruliability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES, "NO 0
If you have checked 'LEs,please indicate the type of coverage by checking the appropriate box below.
LABILITY INSURANCE POLICY Pr 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
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in corn Ii ce with all Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTERNAME Mere$) .i.., LICENSE# I7`irla— SIGNATURE
COMPANY NAME:)//2 � h Pf0.n6�bs r Neolt,tis ADDRESS' CI 1"4 tee✓,(II c_ '
CITY: 1',`Crrct.icor STATE: Pt. ZIP: 0(S7C. FAX
TEL S 1(39 CELL'alcfMAIL: N.0PisHn P(wwr6r%V( iq-100,Gor+-1
MASTER 0 JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0# PARTNERSHIP 0# /� LLC❑#
ROUGE!GAS INSPECTION N2TyS THIS PAGE FOR INSPECTOR USE ONLY . FINAL INSPECTION NOTES
e/2lt 4i /G` `/17 Yes No
/ THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT►
PLAN REVIEW NOTES