HomeMy WebLinkAboutBldg-20-002157 _'��- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
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v-s; CITY /c-�w.c.� 6 PERMIT# � O
JOESITE ADDRESS 1l /7c.-7 'Iciw4ts- rt.c-c-c-mot OWNERS NAME Pe c ...c hi 6 cc L,ec
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES E NO❑
APPLIANCES FLOORS-4 6CiJ 1 ? 3 1 5 6 9 10 VI 12 I--'.��_I
BOILER
BOOSTER 1
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER --1
DRYER '
i
FIREPLACE
FRYOLATOR ______1
FURNACE
GENERATOR
GRILLE o Lib i cb __I_'
INFRARED HEATER __I,
LABORATORY COCKS .
MAKEUP AIR UNIT
OVEN _J
POOL HEATER
ROOM I SPACE HEATER C a v E. 0 _
ROOF TOP UNIT R. - 7
.
UNIT HEATER . ` 1C{.II-MI
UNVENTED ROOM HEATER 0 I
WATER HEATER gip•! G DEPAFz!, NT
OTHER _____I_ �1=cee-5 dt-- t 5 ,,c, IV,:_ii ---------- -
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INSURANCE COVERAGE �
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES D/ICIU ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TI-IE 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
'i- 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 w€ II Pertinent provision o'the
- Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME G(ems,w �., 5L zr- LICENSE#z O) 2- I SIGNATURE
MP ❑ MGF❑ JP JGF❑ LPG'❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY� NAME ADDRESS �0 I�'2.c.`Lc►-5 1l5 PC),
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CITY //�('w r'c. -- y STATE / / ZIP G a-6 TEL TEL 77 - c/9-O5/G
FAX CELL EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ��`y j
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pa(i- ` FEE: $ PERMIT 1 z ,e, !g /�
PLAN REVIEW NOTES
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