HomeMy WebLinkAboutBldg-20-002938 •
I>MIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FlTT
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V �" CITY Il /1'10
== " MA DATE li'—1 y./
PERMIT#hLJl�y-p_aj
JOBSITE ADDRESS 410 S'1 fred eAc LAat.
GOWNER'S NAME �LL. .-- te,
OWNER ADDRESS y0 S.I I v,4/ex( L A-17-e _. TE0-00 Y63- r3 sr
TYPE O> Fny
PRINTOCCUPANCY TYPE COMMERCIAL
CLE ❑ EDUCATIONAL ❑ RESIDENTIAL
NEW: RENOVATION: ❑ REPLACEMENT:❑
PLANS SUBMITTED: YES 0 NO❑
APPLIANCES 1 FLOORS-4 BSM
MEM BOILER 4 5 6 q =-® I i 14
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• CONVERSION BURNER, ---COOi<STOVE
DIRECT VENT HEATER
DRYER111111111111
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FIREPLACE
FRYOLATOR - NM i
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FURNACE
GENERATOR
GRILLE
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INFRARED HEATER ;
LABORATORY COCKS =_=111MIffm.
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POOL HEATER MIMI
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ROOM;SPACE HEATER _E1 -
ROOF TOP UNIT _
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UNVENTED ROOM HEATER UN S_
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UNITHEA
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I have a current l insurance policy or its substantial equiva INSUet w nhicNCEOhVmee
iabiiits the requirements of MGL.Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Nj 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
�. y signature General Laws,and that m on this application waives this requirement.
permit Pp
''-, SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El AGENT ❑
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 >
`— and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi all Pertinen ()vision
�` Massachusetts State Plumbing Code and Chapter 142 of the General knowledge
1 p Laws. � of the
PLUMBER-GASFITTER NAME 6e(6811 �Lc%
LICENSE#a 6")"y 'IGNATURE
MP❑ MGF❑ JP [251 JGF❑ LPGID ❑ CORPORATION❑iF PARTNERSHIP❑#
COMPANY NAME 64� � L�/� S LLC❑
i e�CY(ce ADDRESS I1 cpQI 4eL til
CITY U. &tato vYIN
STATE fillig ZIP dc}-1( 3 TEI
FAX CELLIsfl9� Y
EMAIL COP red e y19-1.e. co,„ /
_-----_— -- ---------- -- FINAL INSPECTION{NOTES
i€ IS P GE FOR ISFECTOR USE ONLY
OUG)tI GAS I3'�SP'E€=.TI01�I�O�E�S .. .. Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0 1-‘14/1r��C Mg CW
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FEE: $ PERMIT#
/ 4 / 7 Md.PJ _M NOTES ,l