HomeMy WebLinkAboutBldg-19-006670 - "� MASSACHUSETTS UNIFORM APPLICATiON FOR A FERRET TO PERFORM GAS FITTING WORK
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` ice-., CITY We,r YA OOT ( MA DATE AV 23 2a/9 PERMIT*. (T7/ a'4674
JOBSITE ADDRESS /z/ ( • /r/iP 377. f%Aid" /2-2-- OWNERS NAME (C-uN4Nc
GOWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL aA'
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:
❑ 1� PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-1 FLOORS-4 BSIv1 1 ? 3 4 5 6 7 5 9 10 'I1 12 •13 14 1
BOILER
BOOSTER —�
CONVERSION BURNER I
COOK STOVE
DIRECT VENT HEATER
DRYER 1 I
FIREPLACE
i
FRYDLATOR —1
FURNACE I
GENERATOR
GRILLE 1
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN i
POOL HEATER •
ROOM/SPACE HEATER
I
ROOF TOP UNIT • -.. 'n1q
TEST -. �`!` ` r 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
_
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES V.110 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IS21/ OTHER TYPE INDEMNITY ❑ BOND ❑
I
• OWNER'S INSURANCE WAIVER: 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 application waives this requirement.
I
'1 CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
'"i, 1 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 Ir wledge J
`k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance 'h all Pe ' I vision o
`j Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#3/01/ SIGNATURE
MP ❑ MGF❑ JP [/JGF❑ LPG! ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME bpAvAitetzS p f _ ADDRESS 20 Air74/4 .IA/tI
CITY X KW/PO(Jilt STATE 11/4 ZIP 4Z4 73 TEL____,Z24 iM 2 y 1
FAX CELL EMAIL k/efY.Ve9 t` ems' B6'@ M/Z ,62
C 0 1 tO 9i 5 °
ROUG —GAS I1 SPECTI T'M'_'ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ '
FEE: v
PERMIT tE / ) 2- M!`' 9
PLAN REVIEW NOTES
O T U/ 1