HomeMy WebLinkAboutBldg-20-002529 660 41- wi.3r1.�
I .c MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY \/a R SU o�.t\k-\./\ MA DATE to '3 i - 1 9 PERMIT*2/ G"SlO-a1 o�6�i9
JOBSITE ADDRESS 63 IQ ifs \('it o (�5 L \nC OWNER'S NAME 17 __ 1--V k E_
GOWNER ADDRESS
•
TEL FAX
TYPE
OR
OCCUP.AIVCY TYPE COMMERCIAL CI EDUCATIONAL ❑ RESIDENTIAL 0‘ -
CLEARLY NEW:❑ RENOVATION: 2"------REPLACEMENT:❑
PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6
BOILER 9 10 11 12 1=_
BOOSTER
• CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE i
FRYOLATOR _
FURNACE Art IC
GENERATOR - i i
GRILLE
INFRARED HEATER
LABORATORY COCKS _________I
vl, MAKEUP AIR UNIT I
f- OVEN —1
CV POOL HEATER1-1
'2 ROOM/SPACE HEATER
ROOF TOP UNIT
TEST • .
-
UNIT HEATER
UNVENTED ROOM HEATER .
WATER HEATER ,
OTHER _�
_ I i
14
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivale 'which meets the requirements of MGL.Ch.142 YES El
0d
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA .BY CHECKING THE APPROPRIATE BOX BELOW
4:
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY El BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the II
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
' CHECK ONE ONLY: OWNER ❑ AGENT El
SIGNATURE OF OWNER OR AGENT
`.`, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to t-e b o '
`- and that all plumbing work and installations performed under the permit issued for this application will be in compli ncavitfi�all Pe pe .no dge
Massachusetts State Plumbi Code and Chapter 142 of the General Laws.
'
PLUMBER-GASFITT- ,NAME LICENSE#SW__ SIGNATURE
MP ❑ MGF JP ❑ JGF❑ LPG! ❑ CORPORATION❑It PARTNERSHIP El# LLC❑#
COMPANY NAME NAN2 .5 V4-r1JNlG eQ. J ,
� tie_ ADDRESS � � C��Q�' Perry Zb
CITY S a-- STATE On ZIP 0.G 3 ! TEL
FAX CELL EMAIL p/e m Cl M q 4' (OIM[ S ( 10•QT
SOUGH GAS INSFEGTIC3P�(TIQTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ h,•.
a /
i
7 FEE: $ PERMIT# ( /r �! /
PLAN REVIEW NOTES