HomeMy WebLinkAboutBLDG-20-002875 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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44 i\M, DATE 11-/g.-/g PERMIT#1g `g4 o7S
JOBSITE ADDRESS /-S- r JreS L-
OWNER'S NAME_Rai,✓'1 L
G OWNER ADDRESS �74.JN-e- TEL FAX,
TYPE OR
PII'�T OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALtr---
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:
PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS--+ 6SIu1 1 2 3 -1 5 6 7 8 9 10 11 12 '13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACEI
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS _--i
MAKEUP AIR UNIT
OVEN - I
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POOL HEATER • � ;� ; '� . ,�;_
ROOM I SPACE HEATER - ,
ROOF TOP UNIT
TEST -.
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER —[--_I
OTHER
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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 Ergo ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE APPROPRIATE BOX BELOW
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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.
. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT El
`.. I hereby certify that all of the details and information I have submitted or entered regarding this application are_true nd accurate to the best of my knowledge
`,- and that all plumbing work and installations performed under the permit issued for this application will compliance •th all Pertinent pro ' ion of the
� b i' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME (Pie_1-) Dja_V-e- LICENSE#/O 7.C� SIGNAT RE
MP I MGF❑ ❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME i�0Va h i n n L
S �� ADDRESS /Z ��n pork/ eQ c- /T
CITY 02J9�J/s STATE OM ZIP 02.4‘ .& TEL.9)r S--Z✓)_
FAX CELL 5-e, 3y`54.od/'o6 EMAIL
SOUGH GII+(SP'EcTIOJ NQ E' • THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ CX�
FEE: v PERMIT# "!/
PLAN REVIEW NOTES
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