HomeMy WebLinkAboutBLDG-15-000005 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT T
f, TO PERFORM GAS FITTING WORK 4/15--(1,15—
,.-"- -E--- ' L. MA. DATE 7-1—/ PERNdI
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CITY: /Vlst'b.,c..-
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JOBS! ADDRESS: 6,67 wfi�COW OWNER'S NAME Let-- Ge-v''/1I'Q
GOWNER ADDRESS: TEL FAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIgI�_
PRINT
CLEARLY RENOVATION:0 REPLACEMENT',r`::! PLANS SUBMITTED: YES 0 NO❑
APPLIANCES-1 FLOOR Bmt 1 1 2 3 4 5 5 X 8 1 9 10 11 12 13 14
BOILER
BOOSTER L I I I I
CONVERSION BURNER
COOK STOVE I I
DIRECT VENT HEATER I
DRYER I I
FIREPLACE I I
FRYOLATOR I I I
FURNACE I I I
GENERATOR I
GRILLE I
INFRARED HEATER I I
LABORATORY COCK I I I
MAKEUP AIR UNIT I I I I
OVEN
POOL HEATER •
ROOM/SPACE HEATER, I I I
ROOF TOP UNIT
TEST I I I I
UNIT HEATER- I
1 UN'VENTED ROOM HEATER I I I I I
I I I I
I I� I I I I I I I
•1 II II 1 Iu Inti I I
i t I I I I I I I
FITMENT INSURANCE COVERAGE
have a currrefit'tiablitv insurance policy or its substantial equivalent which meets the requirement of MGL Ch.142 YES4NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WARIER:I am aware that the licensee does not have the insurance cove-age required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit appcation 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 tine and accurate to the best of my
Knowledge and that all plumbing work and instllations performed under the permit issued for this application will b ' ompliance with all Pertinent
provision of The Nassaohusetis Stale Plumbing Code� and Chapter 142 of the General Laws. p
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PLUMBS GASFII ItitNAME: 77 C re..4'J/� LICENSE4Mitt tAt SIGNATURE
COMPANY NAME tt rcaoLta. 0d ADDRESS: to.2S
CIN L ,ySI) a vt1 STATE �`7_ ZIP: 02-6 Sf FAX:
TEL CELL;c0g-2373E-7f- pdpJl
MASTEE JOURNEYMAN❑ LP INSTALLER 0 CORPORATION 0 r PARTNERE-IP 0_ LG 0
OUGII GAS I SPEC' • • _E' 'MIS PAGE FOR INSI'ECI'OI.un ONLY yINA L INSPECTION NOTES
YDS No
THIS APPLICATION SERVES AS TMC PERMIT ❑ U
FEE: $ PERMIT IF
FLAN REVIEW NOTES
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