HomeMy WebLinkAboutBLDG-20-002310 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
itiitt_P6F CITY p(r G it QGC J MA
MA
DATE D hJ PERMIT# II�G^ Q�CO,?'�O
JOESITE ADDRESS 5lad4 ��C (7GG/O//� OWNER'S NAME gage ggee( C•
OWNER ADDRESS TEL-50P-^p "4/3q FAX
TYPE OR
PRINT PE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED:., YES�S❑ NO ,
APPLIANCES FLOORS-4 BSM 1 2 3 4 5 6 7 9 10 11 12 13 14
BOILER —�
BOOSTER —�
- I
CONVERSION BURNER i
COOK STOVE
DIRECT VENT HEATER --
DRYER —
FIREPLACE
FRYOLATOR '
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
•
MAKEUP AIR UNIT
OVEN
POOL HEATER _ __.. _ .,
ROOM/SPACE HEATER. ,, f
ROOF TOP UNIT _._ _._.____.g
TEST . .
UNIT HEATER --OCT t 201E
UNVENTED ROOM HEATER _ �.__.�
WATER HEATER �� BuiCD6a�
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG- Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ 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,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT j
".b I hereby certify that all of the details and information I have submitted or entered regarding this application are true„sp.
"- and that all plumbing work and installations performed under thepermit issued fortis applicationpwill be in c. ., uratealct C,. ;, b howled
• ith all Pe a• .vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /� j /i i
PLUMBER-GASFITTER NAME LICENSE# 1c9?0 SIGNATURE
MP I MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION Ems' ���� PARTNERSHIP❑#r LLC❑
COMPANY NAME RL�(Js74er" Ara,Pr �,r�e ADDRESSA29 %f(- e-Tree e-
G��J
CITY ft'ete/SS4"'c' r STATE /Gf ZIP (9' � TEL TEL - � (70oZ I
FAX .5rJi 0�:(D�o CELL �/r�'^.5:®��j�D. 3 EMAIL S(..y"(CC0S9B'��`(eWo ? r'(�C. i
ROUGI GAS INSFEc'IIOP(Pfi3JI S THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: $ PERMIT# ✓1/ b•-
PLAN REVIEW NOTES
1