HomeMy WebLinkAboutBLDG-19-001964 -,°` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
6w CITY.11 �Q{�MOJ MA DATE fO-Z.- 2-0I� PERMIT# /` -676 6Q*
JOESITE ADDRESS 12ee Gr'ert-zy et OWNERS NAME-v CO >5`7&-t fin•
OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL PRINTCLEARLY iff'
❑ RESIDENTIAL[
NEW:❑ RENOVATION:Z, REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO r ,
!
APPLIANCES 1. FLOORS-� BSM 1 ? 3 4 5 6 7 2 !
BOILER ______I
BOOSTER —�
1
CONVERSION BURNER
COOK STOVE '
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR i
FURNACE
GENERATOR
GRILLE
INFRARED HEATED. —~
LABORATORY COCKS #i�, 1
MAKEUP AIR UNIT I
OVEN
1 2l e 1
'POOL HEATER • 1 .� (_� / -
ROOM;SPACE HEATER I ' 1
ROOF TOP UNIT ' 1 1 7., i i!__LC.; ., ,frt V
TEST "
UNIT HEATER
INVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of 1 GL.Ch.142 YES . NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ClI
• 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. ;
I
--I CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
sii-, 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
`k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all P rtinent provision of the
Massachusetts State Plumbing Code and Chapter;`
142 of the General Laws.
PLUMBER-GASFITTER NAME Se f_c and „ LICENSE# 1.5"g22 SIGNATURE
MP b< MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# I
COMPANY NAME 0CV\`c...kn szf'-k ADDRESS VD ZO'IC, toa<
CITY Cer.)'f ec\I'\`C_ STATE Mk- ZIP 02-632_ TEL /?` 2S$-G2-Es-fo
FAX CELL EMAIL tick n Cl -i-%0urrt x 1-'.. 010._GI- cm"1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
C ZOd
(a4- P/C/ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
A(.1- 77,r FEE: $ PERMIT#
/47-7Z /Vp/ `
PLAN REVIEW NOTES