HomeMy WebLinkAboutBLDG-15-001719 I MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FII ZING WORK
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. iD t -e—r CITY: c-r,..,.r,,,��_ MA DATE . /ig,V PERMIT stria-fs-a01 fl
�.,�' �- JOESrrE ADDRESS- '/ /7�+�-- -O..�j C e. OWNER'S NAME
• G OWNER ADDRESS: 2t / TEL: FRti
P PEAR OCCUPANCY 1YPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL LFA
C'LEARI.Y NEW:0 P(OVATION:Lys/REPLACEMENT:❑ PLANS SUBMI I I t11: YES 0 NO Ifl
APPLIANCES1 FLOOR Bsmt 1 2 1 3 1 4 5 6 7 1 8 1 9 10 11 12 1 13 1 14
BOILER. I 1 I
BOOSTER I
I CONVERSION BURNER f
COOK STOVE I I I i
DIRECT VENT HEATER 1 I
DRYER
FIFRYOLATOREPLACE _}—�• I I I
R I I I I
FURNACE I I 1 I
GENERATOR I I
GRILLE I I J
INFRARED HEATER I I I I
I LABORATORY COCK I I I I I
MAKEUP AIR UNIT I I I I
OVEN I I I
POOL HEATER I I •
ROOM/SPACE HEATER I I I I I
I ROOF TOP UNIT I I I
I UUNrr HEATER I I I I I t I I
UNVENTED ROOM HEATER I I I
WATER HEATER I I I I I II I '
I I I
I I I F I I I - I I
INSURANCE COVERAGE
1 have a current Habirty insurance policy or h6 substantial equivalentwh ich metes the requirement of MGL Ch 142 YES Orn<0
if you have checlkd YES.please hdicasth>e type of coverage by checking the appropriaa>box below.
UABLLITY INSURANCE POLICY OTHERTYPE INDBVINTFY 0 BOND ❑
OWNER'S INSURANCE WANER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massa chasms General Laws,and that my signature on this permit application waives this requrrement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information l have submitted(or entered)regarding this application are true and accurate to tie best of my
Knowledge and that all plumbing work and instillations performed under tie pennl issued for this applcefon will be ht fiance war all Peril
provision of the Massachusetls State Plumbing Code and Chapter 142 of the General laws.
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PLUMBER/GASH I I thtNAME: 61"e-,— e• S�-C�n-e_ LICENSE# Z02?-1 SIGNATURE
COMPANY NAME: ADaz,a- L� tic cc�y Fo(/, &Cit
cry. 1l�c—L„t e STATE hi/ ZIP: 02 6 YS FAX
TEL: ?79- ?,09-O Wo eau EMAIL:
MASTER 0 JOURNEYMAN L INSTALLER 0 CORPORATION❑# PARTNERS-IP'ERS I!P❑= lie s
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I' r '_ .0► L MC' THIS I'AGEFOR INSPECTOR USLONLY FINAL INSPECTION NOT)s'S
Yes No
TATS APPLICATION SERVES A5 THE PERMIT ❑ ❑
_ FEE: $ PERMIT II —
_ )'LANREVIEW NOTES