HomeMy WebLinkAboutBLDG-15-000061 o � I MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
= GTY: lL'O-.l Mk DATE 7-71 - ( y PERMIT 6J,S1"06/
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JOBS ADDRESS:3 JAl-L'p AR�SL 2 L /'wt1v ?C)4,4�(19
OWNER'S NAME
GOWNER ADDRESS: TEL' FAX
, , TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL(]
PRINT �/ SUBMITTED: YES❑ NO❑
CLEARLY NEW:0 RENOVATION:LV]' REPLACEMENT:0 PLANS
APPLIANCES? FLOOR Bsrnt 1 I 2 3 4 5 1 B 7 1 8 1 9 10 1 11 1 12 I 13 1 14
BOILER I 1 I i I 1
BOOSitK I I I J I I I
CONVERSION BURNER I I I I I
COOK STOVE f I i I i
DRYERI
DIRECT VENT HEATER i I I I I
FIREPLACE t I I I I
FRYOLATOR I I I I 1
FURNACE I • I 1 I 1
GENERATOR I I
GRILLE I I
INFRARED HEATER I I 1 I I
LABORATORY COCK
MAKEUP AIR UNIT I I I I I
OVEN I I I
POOL HEATER I I I • 1_ I
ROOM/SPACE HEATER I I I _ I • —
I ROOF TOP UNIT I I I I
TEST I I I I ._ I
UNIT HEATER I I I i
UNVENTED ROOM HEATER I IIr I
WATER HEA I ttt 1 I I I I I
I l I I I I I 1 I I I
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142 YES 10 ❑
If you have checked YES,please Indicatethe type of coverage b checking the appropriate box below.
LIABILITY INSURANCE POLICYOTHERTYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the fiensee 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: OWNE2 0 AGENT 0
SIGNATURE OF OWNER.OR AGENT
hereby certify that all of The details and'urformation I have submitted(or entered)regarding this application are true and accurate to the best of my I
Know1Sge and that all plumbing work and insthllations performed under the perml issued for this appfgSr• , • +n n all Perfnent
proton of the Massa:husetsStatee P1 mg Code and orer 142 of the General Laws. A f ig
PLUMBERIGASH I I tk NAME 1�V �/ l LICENSE# 1O62 c--- S c�.•TO
COMPANY NAME If 4 j�/U& � &A, 7 ADDRESS:1PD, N •19-C.-
1
CffY:��S7�WS frit (IS STATE Dit, ZIP: 026 FAX:
TEL:5°4 'y26-&. ,r GF,l• 3'd 6 3n-ter& EMIL: 062-3 c6
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MASTER JOURNEYMAN El LP INSTAI I FR 0 CORPORATION De- PARIth$ .-.HLP❑='.— LL f g
' JUL 21 20Th 1
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OUC[[GA ►Sl' r '. IA ► I x' • ''IIL4FACE FOILI arI'OItUSE ONLY FINAL JNSI'ECVION NOTES
Vas No
TIIIS APPLICATION SERVES AS TIIE PERMIT 0 ❑
FEE: $ PERMITd
PLAN TIMMY NOTES