HomeMy WebLinkAboutBLDG-15-000060 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
t' am 7.4-114.-ud!'l- Mk DATE: a '3& "/ 9PERWdT# b`r 0
�'t 60-
JOBSITE ADDRESS: 9 I W/(loco sr OWNER'S NAME
]" OWNER ADDRESS: SA-ttiG a FAX
P�RIEtvT OCCUPANCY TYPE f�—COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0
CLEARLY NEW:0 RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
APP LLAN CES1 FLOOR—i• Bsmt 1 1 2 3 1 4 5 1 6 7 1 8 9 10 11 12 13 1 14
BOILER I I 1 I I
BOOSTER
I
CONVERSION BURNER I I I I
COOK STOVE I I I i I
DIRECT VENT HEATER
DRYER I
FIREPLACE I I
FRYOLATOR I I I f
FURNACE I I
GENERATOR I ,1 I I I
GRILLE I I
INFRARED HEATER I I I I I
LABORATORY COCK I I I I
MAKEUP AIR UNIT I I I
OVEN I II I II _ I
POOL HEATER •
ROOM/SPACE HEATER I I I Ifill
I ROOF TEST TOP UNIT I I/ 1� i I •I IL° 'La` _t S
UNIT HEATER I{
UNVENTED ROOM HEATER I_ I tJ I 'jU I I
I WATER HEATER I I I I
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I I I I I I I Stitt al
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES NO 0
If you have checked YES please indicate the type of coverage by checking the appropriate box below. On t tt/&rc57'
LIABIUTY INSURANCE POLICY pr OTHERTYPEINDEMNITY 0 BOND 0 so
OWNER'S INSURANCEWAIVER I am aware that the licensee does not have the insurance coverage required by Chapter142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
•
CHECK ONE ONLY: OWNER 0 AGENT 0
` SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true • accurate to the best of my
Knowledge and that all plumbing work and installations performed under the pewit issued for this application • . r.$ . I Pertinent
provision of the Massachusetts State Plumbing Code and Cha ter 142 of the General Laws. - as,
PLUMBFRICAS, I I II xNAME ' OrPed/,, �/ r LICENSE ` O423 - S GNAT'
COMPANY NAMtE•/PD& Uc /I/ X 6"j 1/ A ADDRESS: /(0 `' vC•2
Cut:P'*4J c3 M k S STATE U"UI/ — ZIP: fJ FAX
. a . 6 -r-- C L' et333—AloApa:
MASTER ll• JOURNEYMAN 0 LP INSTALLER❑ CORPORATION❑g PARTNERS'IP❑g LLC❑
4-141-
OUG G S INSI'I's ."_ •A I • t• THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
%R(oh ;/5 (1rLGnlj l Yes No
TIIIS APPLICATION SERVES AS TIIE PERMIT ❑ 0
FEE: E PERMIT G
—
)'LAN ItJYIEIY NOTES