HomeMy WebLinkAboutBLDG-15-003327 MASSACHUSETTS UNIFORM- � APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY . hi-MOIL, � I�b 1`� - — 1 MA DATET /2- ! - _PERMIT# �i iret '�'3in
JOBSITE ADDRESS BO-5 Mali- ter C• I OWNER'S NAME L-.E D 6 -f5.
1 G OWNER ADDRESS ~ A. -/f is _. I TEL;kCe-' 62-7-5S22)--
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TYPE OR OCCUPANCY TYPE COMMERCIAL as, EDUCATIONAL I RESIDENTIA�I
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CLEARLY NEW: • RENOVATION:iL,-i REPLACEMENT:5Z PLANS SUBMITTED: YESI- NO__..
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 _ to 11 12 13 14
' BOILER Issiastnsggi_ -
BOOSTER IIII .aSrIiiMilailitiilli- -_
CONVERSION BURNER Lr f.. W M- a.
COOK STOVE 1`► -S —i'l M1 SI -
I DIRECT VENT HEATER INS irstriu-SMIUSSIIIIIISSISIMMIliat '
DRYER S I M1S. -
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GENERATOR SrJS-.S L L
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INFRARED HEATER LeWi IM
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LABORATORY COCKS ismajotisiwiensignaillearnialtelli1011.11-1
MAKEUP AIR UNIT itilSri_r- T NSi
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ROOM/SPACE HEATER e_a __ .
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INSURANCE COVERAGE
equivalent which meets the requirements of MGL Ch.142 YES NO
I have a current liability insurance policy or its substantial egbi
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 7 BOND L=
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 rAGENT `-,.
SIGNATUrtE 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 best of my knowtedgi
and that all plumbing work and installations performed under the permit issued for this application will be in con'ptiance wt ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L. �C.i-
PLUMBER-GASFITTER NAME;_iv 1 H tom'1�,CE -'td1J LICENSE ttiT! S� SIGNATURE
MPX MGF--_ JP___ JGF LPGI im CORP0RATION,s''±}71 I PARTNERSHIP Dtli=— —i LLC LY#——_
• I COMPANY NAME:4t n).abc.7-t s 6-f f Faf.4'ADDRESS; 13 CC/,Q...tt�_F - __ -� ----
CITY • 1 /!1 ri f Alf° i STATE fl1A, IZIPa 7E,Z iTELI, T 6'S9 :
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
— Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S --�._ PERMIT N-- —
PLAN REVIEW NOTES