HomeMy WebLinkAboutBldg-19-001915 ... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
c . 6' CITY f M0A` MA DATE 1.-IA`' PERMIT 4&-.40b,'11 ,9/c
JOBSITE ADDRESS 1 0 nV mot' ,n 6.
( - OWNERS NAME i?),1, <Ontne 1 k_
GOWNER ADDRESS TEL-)5( ai-vs Lk u k FAX
TYPE OR. 00CUPANCY TYPE COMMERCIAL
P � ❑ EDUCATIONAL ❑ RESIDENTIAL
F
CLEARLY NEW:E RENOVATION:r REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-1 FLOORS-* BSM 1 2 3 1 5 6 7 R 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER ,
COOK STOVE
DIRECT VENT HEATER
DRYER r L_--_I
FIREPLACE
FRYOLATOR '
FURNACE
GENERATOR Y
GRILLE
INFRARED HEATER ------1 I
I i
LABORATORY COCKS _.. _._ -a. .__...._„,.-. , ,, i
MAKEUP AIR UNIT a. � "
. ,OVEN : ._.._.
POOL HEATER • 1
ROOM I SPACE HEATER Or (I 1 Z(�1
ROOF TOP UNIT t
TEST ".. . . ... . ..
UNIT HEATER __. ..- _
UNVENTED ROOM HEATER •
WATER HEATER
OTHER
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES KrNO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 3 OTHER TYPE INDEMNITY El BOND El
• OWNER'S INSURANCE WAIV . an aware that the licensee does not have the insurance coverage required by Chapter 142of the t
(Massachusetts General I s,an la .ii nature on this permit application waives this requirement.
' CHECK ONE ONLY: OWNER W- AGENT ❑ 1
`', S 3 I .' OF OWNER ,AGENT
I hereby certify that all e details and information I have submitted or entered regarding this application are true and a a` the best of my knowledge 1
`-- and that all plumbin work and installations performed under the permit issued for this application will be in complianc ith n it provision of the
`` Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#31.41 SIGNATURE
MP ❑ MGF❑ J rAr JGF El LPGI CORPORATION❑4 PARTNERSHIP❑#1: LLC❑## p I
COMPANY NAME `` QS\' ,-9, L ADDRESS 3 r8 0/ C e)
CITY L trivb. \ S TE ZIP O c TEL 94- ar-30 L1
V CELL EMAIL `n,T r
FAX S J A In �j OB
J yc bc). G
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
T?&//- (e) ,,,--, THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
/ l n FEE: $ PERMIT lI • l 4
PLAN REVIEW NOTES `' ` / 60(
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