HomeMy WebLinkAboutBLDG-20-002356 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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� �1l� MA DATE Jo 5 /g PERMIT a�4
JOBSITE ADDRESS t34t),(361 LRi • OWNERS NAME A IrI W C(rr-
G OWIJERADDRESS I TEL C7--Y3' ^C.�/ Shy
TYPE OR
PRINT PE OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL EL/
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:
PLANS SUBMITTED: YES❑ NO 0
APPLIANCES 71- FLOORS-' SSlul 1
5 6 9 10 11 12 = 1=
BOILER
2
BOOSTER
CONVERSION BURNER
COOK STOVE
r
DIRECT VENT HEATER
DRYER � :
FIREPLACE
i
FRYOLATOR
FURNACE —J
GENERATOR �J
GRILLE •
I _J
INFRARED HEATER ._ I
LABORATORY COCKS -
• MAKEUP AIR UNIT j
OVEN �_— I
•
POOL HEATER
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST 41j `-h r_'01 ; -
.__ _ ._ ....__. _. 4
UNIT HEATER _ .._.... .
UNVENTED ROOM HEATER •
WATER HEATER ��
OTHER
1
INSURANCE
GE
I have a current liability insurance policy or its substantial equivalent which meetsthe requirements of MGL.Ch.142 YES �p ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY
❑ BOND 0
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
•
CHECK ONE ON : OWNER ❑
SIGNATURE OF OWNER OR AGENT / NT ❑
I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate to the bes . my knowledge
v`- and that all plumbing work and installations performed under the permit issued for this application will be in compf e with all re
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. sion of the
PLUMBER-GGASFITTER NAME LICENSE#3?S"j SIGN) RE
MP ❑ MGF❑ JP 0 JGF LPGI El CORPORATION 0# PARTNE
RSHIP CRSHIP 0# LLC 0#
COMPANY NAME 4111AV -46E / -1-41e - - ADDRESS & F43c'4/1/4.1 l -
CITY (Cy 2T H STATEV1 - ZIP Qd_?6O TEL (d -7S G
FAX CELL EMAIL A6E ifo t( 47c,06.,-cam
OUGH GAS INSPECTIQN NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ — 407(
•
FEE: $
PERMIT# el 4 //7 /7
PLAN REVIEW NOTES