HomeMy WebLinkAboutBLDG-15-003364 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'l
' ) CITY \ Lr MA DATE /���//� PE IT#� D60�033 1
JOBSITE DDRESS '. a / I/ n/ A. Cf"- .:21-1
NAME 1 L Ill I 12 e
G OWNER ADDRESS lam
TEL ✓'1�-10;) FAX 1 ,,
TYPE OR OCCUPANCY TYPE COMMERCIAL 14 EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY .NEW:❑ RENOVATION:Eg REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO[ I \,
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 I
BOILER
BOOSTER r'
CONVERSION BURNER •
COOK STOVE .
DIRECT VENT HEATER
DRYERs.s1
FIREPLACE I
FRYOLATOR '_I'
FURNACE _
GENERATOR _
GRILLE _ _
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT - .
OVEN • .
POOL HEATER
ROOM/SPACE HEATER -
ROOF TOP UNIT
TEST it1TD X ...
UNIT HEATER
UNV.N ILa art rra 'IP' EgEt. n>
WAT' R '1' ., /[y'u ti. C.r - •
OTHI R /ffllf `f i j _ ,
DEC 16 2014 41
«' INSURANCE COVERAGE
I hay . ••r u ance •o I y or its substantial equivalent which meets the requirements of MGL.Ch.142 YES X] NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I4 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: OWN R p 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 are_ - .nd -- urate to the best of I. . edge
and that all plumbing work and installations performed under the permit issued for this application will be in ,.i p -with all P-rtintnt pr. on of the ,
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE# 4 SIGI'IAT •E
M MP❑ MGF JP❑ JGGF❑ LPG]❑/ CORPORATION®# $iC PARTNERSHIP❑# f J LLC❑#
vs, COMPANY NAME
'►0Db J 5 P avant Gjasinc_. ADDRESS Pa 80 - [ a
CITY Westll.�.1-r WA—a STATE Iltil ZIP 0 a51149 TEL S($'a95 ��?r
FAX 508-aqi -Oil Es3 CELL EMAILl� .' flX1& Oh I 5/A
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zPECTION NOTES S ' E FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
710T 93d v/J�n(j TM , Yes No _
f1Cf /pAn 4 y THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
may` FEE: $ PERMIT#
'tn.� � PLAN REVIEW NOTES _
Uv,C 1/441-0#
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