HomeMy WebLinkAboutG-12-660 • __, sz,
?
MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK
` t`I= '1/4 CITY IYamauth
I. MA DATE 4-
I � Z1// I PERMIT#G12-
G JOBSITEADDRESS I ??7 1Ut le A l I / OWNER'S NAME I/�-J 7 66U— /04,CH
TYPE R OWNER ADDRESS: I I TEL: 1 D 7bd 277,1r I FAX ICS.7dd/, '3
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0
PLANS SUBMITTED: YES 0 NO❑
FIXUTRES Z FLOOR-. Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER �c E C E i v E D I
COOK STOVE
DIRECT VENT HEATER
FFIREPLACE YR 20 2
0 FRYOLATOR
```O►► FURNACE 3UILr INGCEPAR N1
be GENERATOR aY; —
J\� GRILLE
LABORATORY COCKS
00MAKEUP AIR UNIT
4 OVEN
POOL HEATER
ROOM I SPACE HEATER
`, ROOF TOP UNIT
TEST
UNIT HEATER
INVENTED ROOM HEATER
*TER HEATER
if (I0,6 .4e/-c-I�we—
NI P2114 GS°. /11)02-115
I\
s) I have a current liability insurance policy or its substantial equivalentCE which meets the requirements of MGL Ch.142 YES 4&N0 0
yIf you have checked y,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not havq the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application mgt this requirement.
SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER 0 AGENT 0
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
Knowledge and that all plumbing work and Installations performed under the permit issued for this ap
pl provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. j/ will ,: I co .It...: au pertinent
NAME: I/L� �,w�
} p-La-- I LICENSE 41 Urn I I TUR A
COMPANY NAME:I1444/IY/1N pjepp E, IADDRESS:1(0 15 OX /7.ry7 I
CITY: 15. 06tekyJ/s ISTATE: Ltil ZIP: I ozzeto J FAX: I,OJ'-I6d./9331
TEL: I laud I EMAIL• I I
MASTER 0 JOURNEYMAN 0 LP INSTALLER CORPORATION 0#1 (PARTNERSHIP 0#I I LLC 0#
•
1,"
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES ‘4"ed
ROUGH GAS INSPECTION NOTES _
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 '
FEE: $ PERMITI
PLAN REVIEW NOTES
Cr' l l
•
`p� I1
�� pt d
is, 1 /
, •�'
Fri 4s
-P � � ��
�tVlitc.._- - ..4,S t 1.1,1 V I .
1 /`�
JN .