HomeMy WebLinkAboutBldp--19-001477 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I
• �, k �, N" �j CITY r t�Ov MA DATE `��`�� PERMIT* /*-4b-/9-001`/4
JOBSITE ADD . SS *7 n 00 I&IL" S OWNERS NAME at tek. CQ,, tit
GGWNERADDRESS d 114r`' tit- uk.9{ Oil TEL 7 1 aL1$ 1-1)a1 FAX
TYPE OR OCCUPANCY TYPE COMMERCIALEDUCATIONAL Pry ❑ ❑ RESIDENTIAL El
CLEARLY NEW:` RENOVATION:1 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1. FLOORS- 6SIO ?1 _ 3 1 5 6 7 8 9 10 11 12 13 14
BOILER —1
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR '
FURNACE ____I
GENERATOR
GRILLE
INFRARED HEATER `
LABORATORY COCKS
MAKEUP AIR UNIT r-- ~ i
OVENt.! sEP ir 1 1140 I i
POOL HEATER •
ROOM!SPACE HEATER - ---I
ROOF TOP UNIT , �l '�
TEST . _ Ii
UNIT HEATER
UNVENTED ROOM HEATER :C_.....7-1_ I
WATER HEATER i
OTHER I '
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of[VIGL.Ch.142 YES O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY ❑ BOND ❑
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 . that my sign• re on this permit application waives this requirement.
I
CHECK ONE ONLY: OWNER ri1 AGENT ❑
• SIGNAT 4•/OF OWNER OR AGENT
I hereby certify that all oft : details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge I
�; and that all plumbing work and installations performed under the permit issued for this application will be in compliance Pent provision of the
LIJI Massachusetts State Plumbing Code and Chapter 142 of the General Laws, I
PLUMBER-GASFITTER NAME 1
J vS ,h LICENSE#�3ay tJ- SIGNATURE
MP ❑ MGF❑ JP Tr JGF❑ LPGI ❑ CORPORATION 0# PARTNERSHIP E]# LLC 0#
COMPANY NAME—S.A.\- U(4.b"t ADDRESS .n v� 'iraa le Ad
t_�
CITY S u,t Mo,1�" \ STATE kit ZIP 66 Lk TEL Sbt- D3)^36 9 L 1
FAX CELL EMAIL l?M bv, Vb° ,co.^'\
ROUGH GAS INSPECTION NOTES TI M,S PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
(��� �s��� �� THIS,AAPI.ICATIONSERVES AS THE PERMIT ❑ ❑
� — l ,v
FEE: $ PERMIT# 1/ 9 / ( 9
PLAN REVIEW NOTES
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