HomeMy WebLinkAboutP-20-1982 � - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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t ,r,s` CITY_____4(4. J MA DATE 6 y ' PERMIT
JOBSITE ADDRESS 2Z 6r'it 1/41 Sa+i1 sJ. kw- I'1 OWNERS NAME ,1e4 :Ai, YT1 i
GOWNER ADDRESS TEL zeol-Fz FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:kir PLANS SUBMITTED: YES❑ NO❑
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APPLIANCES 1 FLOORS--F BSM 1 2 3 4 . 5 6 7 8 9 10 11 12 13 14
BOILER ---1
BOOSTER --1
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER I
DRYER
I
FIREPLACE '
FRYOLATOR
FURNACE / _
GENERATOR I I
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN ( L
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER _
UNVENTED ROOM HEATER ___
WATER HEATER
OTHER , \--.)--- ,
l
-1 I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.'142 YES` ] NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �� ``
•
• LIABILITY INSURANCE POLICY K OTHER TYPE INDEMNITY ❑ BOND ❑
• C1WNER'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
•1I-2 I 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 knowledge
`� and that all plumbing work and installations performed under the permit issued for this application will be in compliance with;,, 'rti r n of the
Massachusetts State Plumbing Code and Chapter-142 of the General Laws. �
`mot l�,_'
41111
PLUMBER-GASFITTER NAME 7` `& S bk ),N LICENSE# /5577# .NA 1,E
MP MGF❑ JP ❑ JGF❑ LPGIGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑
COMPANY NAME S/(4&L C[ �1 I� i Ut/a1450°43' I P-i ADDRESS Cr/ Si—
CITY Ve5t t'")le ivki.5 "'r )ie STATE /711 ZIP 02 (/ 4,Q TEL = 2/2 f 32�
FAX CELL EMAIL bill)l' 0 6/-2/f/L - Cruet
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
k / THIS APPLICATION SERVES AS THE PER1k1IT ❑ ❑ ,/.; l a
/4 FEE: $ PERMIT 16 `/ ' 4/5—je?
PLAN REVIEW NOTES