HomeMy WebLinkAboutBLDG-15-001423 s' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS Ell l"ING WORK
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E ,/ CIN: SD Q69.4942.rg r kb4 DATE g--19--/f PERM7#Pt/615100 M,2/3
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s J08517EADDRESS- T /rl4yiCAOWlf PItPWNERSNAME%ric 77///ao
G OWNER ADDRESS: 54:447L 0'x,4 TEL: FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALa—'
PRIItT — /
CLEARLY NEM.❑ RENOVATIOIJ:I�' REPLACEA4ENT:❑ PLANS SUBMI I 1 EU: YES E NO Bim'
APPLIANCESI FLOOR Bsrft 1 2 3 4 5 5 7 1 8 9 10 11 12 1 13 14
BOILER f/ I I
BOOSTER
I CONVERSION BURNER I I
COOK STOVE I A I
DRECT VENT HEATER I
DRYER I I
FIREPLACE I I
FRYOLATOR I I
FURNAAT • . r.._--.1
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GENERATORI
GRILLE I I
INFRARED HEATER I I I
I LABORATORY COCK
i I MAKEUP AIR UNIT I I I
I OVEN I I
I POOL HEATER I I I i
I ROOM/SPACE HEATER I I I
I ROOF TOP UNIT I I I
I TEST 174-11
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I UNVENTED ROOM HEATER r I I I I I I I
WATT HEATS I I I I I • I 1
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INSURANCE COVERAGE
I have a current Babirrty insurance poky or its substantial equivalent which mess the requirements of Oh L 1�EP 2'� F
If you have checked YES,please indicate.the type of coverage checking the appropriaa box below. RU I L D1 A R9*idled
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LIABEITYINSURANCEPOLCY OTHER TYPE INDEMNITY' ElBOND ❑
OWNER'S INSURANCE WAVERIamaware that thelicenseedoesnothavetheinsurancecoveagerequiredbyChapter142ofthe
Massachusetts General Laws,and that my signature on this permitappflcadon waives this requirement
CHECK ONE ONLY: OWNER 9 AGENT 9
SIGNATURE OF OWNER OR AGENT
hereby cert y that all of tie details and information I have submitted(or entered)regarding this apptcation are true and accurate to tie best of my
Knowledge and that all plumbing work and insiallafions performed under the permit issued for this application will be hi ompfiance, '" all Pertinent
provision of tie Massachusetts State Plumbing Code and Chapter 42 of tie General laws. / / /
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FLUMSEWGAS-Ii TtRNAn41/A77:,
E ��,�Lr/C �D��'�I�R LICENSES ���/ - SI 'i.
COMPANNY�Y NA3 E///I,�, 1/A7'4/. 1/4/106 l ADDRESS: 14' 7/4ff5I CU
CITY•-5,9 <4C rZi#of/ STATES- ZIP: C'8 • FAX /
TEL- I .. • t' # %. au . C9cC9 076- g""—.t:,
MASTER 0 JOURNEYMAN ,PINSTALLER❑ CORPORATION 0g _ PARTNERSHIP❑= LLC 0g
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�► ► � . P ' TIIINPAGE FOR 1NSPECPO11USLONLY FINAL INSPECTION NOTES
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�6)44l-1 TI IIS APPLICATION SERVOS AS TIIE PERMIT ❑ D
FEE: $ PERMIT/
)'LAN REVIEW NOTES