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HomeMy WebLinkAboutG-15-219 b • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 4 Ke hey V�= CITY 4 ..w•.,fi1.for} 1 MA DATE 'j-a$• fir/ PERMir# f3i06-/si'to aic; JOBSITEADDRESS_y4 ti</C41hrt 41/<, jOWNER'SNAME jAkin a,;1 (... hif:c . 1 GOWNER ADDRESS N4 ftcr'(, tr 4„c Ycrwwdtc,poilTELl,fbb-Q)7.W67 JFAX[ _ ., 1 TYV- P OCCUPANFYTYPE COMMERCIAL RESIDENTIALEDUCATIONALC RESIDTIAL CLEARLY NEW: / RENOVATION:a REPLACEMENT:© PLANS SUBMITTED: YES© N00 APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER - BOOSTER COOK STOVE DIRECT VENT HEATER I DRYER FIREPLACE FURNACE INFRARED HEATER , LABORATORY COCKS OVEN - ROOF TOP UNIT TEST .1 UNIT HEATER I —,— 1 -11 , ' la , .... . ,.. __ . ___, ISa a f� fl SWAISSISSMS MI ,�S eg NI FINIINS4illitiisi _ _ /4 INSURANCE COVERAGE BUIuDING -.:: - TMENT olicyoritssubstantialequivalentwhichmeetstherequirementsofMGLC Ih. �xwrr� r '_.::.,.:._..._- ..__ . h.142 YNO © I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY411 OTHER TYPE INDEMNITY © BOND 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 © AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the bast of my knowledge and shat all useplumbing workmbnd Cod installations pten1performed underfththe permitl Issued for this application will beall Pertinent provision of the Massachusetts Slate Plumbing Code and Chapter 142 of the General Laws. v �� PLUMBER-GASFITTER NAME 15.:,,rl`�/ G rcNn 1.IA. =LICENSE#/o)yy SIGNATURE MP MGF 9 JP© JGF 0 LPGI© . CORPORATION D# - PARTNERSHIP©# .1 LLC©# COMPANYNAMEj l ..."-,Pa le. +.4-1. 1ADDRESS (3oy 102.c CITY _J V .a.s iii,..,.•..r . ,4 ... .. . I STATE IJ/3 ZIP 024 s/ ,TEL 4 FAX kali _ _ EMAIL _ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No Ohl (2AS Fr+2.€ pit of THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# #6/f 0/1S diercL »,i& , PLAN REVIEW NOTES 1 (6'1cc:,F rt,/e) Pais 6,,,--g en alt livey sALC Gh' G F on aA) Forte Per •C `'eici If 9/7//i c . • • v