HomeMy WebLinkAboutBLDG-20-002469 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
EMI.,
. CITY ��� �1,
;� ham, DATE 20 /2S / I S PERMIT# *-1Xr'�p--alo1._
JOBSITE ADDRESS /or �cd-Ler ( J Or- OWNERS NAME '�_�f seaG r�`1
OWNER ADDRESS 2;2 f'S f-1-Lartr Wood TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL N.,
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT:IN PLANS SUBMITTED: YES❑ NO
APPLIANCES-1. FLOORS-4 BSM 1 2 3 4 5 6 7 0 9 10 11 12 '13 14
BOILER
BOOSTER
• CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER (------- -) ,
DRYER ��
FIREPLACE I
KFRYOLATOR
FURNACE l
GENERATOR jGRILLE
INFRARED HEATER j
LABORATORY COCKS
MAKEUP AIR UNIT --�
OVEN �l
® fl V
POOL HEATER • C
! ROOM I SPACE HEATER a Qq
ROOF TOP UNIT -( 10�7
TEST - �,.�
j �N
UNIT HEATER = _
UNVENTED ROOM HEATER gv-�;piG .-
WATER HEATERey ._ _
0 OTHER
4° 1 l
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [IV NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY N OTHER TYPE INDEMNITY ❑ BOND ❑
•
, i 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.
' CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 the best of my knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
" Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LU
PLUMBER-GASFITTER NAME Qir,i„ O\Sy. LICENSE# Z6/ 2 SIGNATURE
MP❑ MGF❑ JP JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME e'3 C 5o b9- - I ADDRESS Z3 5 4q J/cam vc,„0, L,.
CITY Vt7 o-<-l.. STATE p► - ZIP C3 L1 CO TEL
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
• FEE: $ PERMIT# fLP/vifY
PLAN REVIEW NOTES
42