HomeMy WebLinkAboutBLDG-15-000055 1 I MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
s. 7-1 $-8 PPERMR# V./ - JV
r CITY: yi�nw� 5 p -^ q MA. DATE lx�ol . ..oro
JOSSRE ADDRESS /ler7Y AL.. W `!a re wftn oWNER's NAME
G OwNERADDRESS: &pit TEL: -50a-Vico-737C FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL LvJ
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:Lh PLANS SUBMI I I tU: YES 0 NO❑
APPLIANCES1 FLOOR-. Smt 1 1 2 3 1 4 5 6 7 18 9 10 11 12 13 14
BOILER 1 I
BOOSTER I I
CONVERSION BURNER, I I
COOK STOVE I I
DIRECT VENT HEATER
I DRYER I
FIREPLACE I I I
FRYOLATOR I I
FURNACE 1 I I . • I I
GENERATOR I I
GRILLE I I I
INFRARED HEATERI I i 1 I _
' LABORATORY COCK I . I I I I
MAKEUP AIR UNITOVal I I I I
POOL HEATER I I • II I_
ROOM/SPACE HEATER I I 1 IL IL
I ROOF TOP UNIT 1 1 I I
I TEST I I I I I I
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UNVENTED ROOM HEATER E I
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INSURANCE COVERAGE
,--112L--1- h /� current liability insurance policy or its substantial equivalent which meets the requirements of NIGL Ch.142 YES LINO ❑
If you have checked YES,please indicate the type of coverageerby checking the appropriate box below.
LIABILITY INSURANCE POLICY Iy OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit appIicaon waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby cer¢iy that all of the details and information I have submitred(or entered)regarding this application are true and accurate to the best of my I
Knowbdge and that all plumbing work and instillations performed under the permit issued for this apprrafon v • compliance with all Pertinent
proton of the Massachusetts Stale Plumbing Code and Chapter 142 cite General Laws.
PLUMBERIGAS1-SI ItiNAME, RICA tvjt,(ed line LICEI4SE# I� 't Or COMPANY E .a Pio J410.‘3 t line ADDRESS: /4 5A$'CS v,
CITY• ra"k STATEN-PA- ZIP: oZrPICC- FAX:
Ta: caL: 5)8-24- 7375 EMAIL: r f,,441 k.. !o ,r psr cult ran
MASTER E/JOURNEYMAN 0 LP INSTALLER 0 CORPORATION 0 s PARTNERSHIP 0 4 LCQ
OUG [Ga51 SFr �, � � �'11151'A41:volt lS11 C1'ORUS[:ONLY FINAL INS l'ECIION NOTES
Yos No
THIS APPLICATION SERVES AS THE PERMIT 0 El
FEE: $ PERMIT G —
)'LAN REVIEW]VOTES
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