HomeMy WebLinkAboutBLDG-20-002468 '` MASSACHUSETTS/ UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�'=�. i CITY 'Its' \ f
r J MA DATE IC7 /25 I PERMIT#J 6 ---dO Qq
JODSITE ADDRESS 100 1-1(4-l.er(, , c {k OWNER'S NAME_t`'1 C S 1^Zg,,,,
GOWNER ADDRESS 2) Z2 )4<i -\es- Lt000( TEL FAY,
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL'
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENTS PLAN..S SUBMITTED:
YES❑ NO
APPLIANCES-1. FLOORS-•+ SiBul 1
3 4 5 6 7 8 9 10 11 12 Ig 14
BOILER
BOOSTER
CONVERSION BURNER -
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE -,,
FRYOLATOR `
FURNACE I _1
GENERATOR
GRILLE
INFRARED HEATER -
LABORATORY COCKS ______.1
MAKEUP AIR UNIT •
OVEN •
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT ' E f)
_
TEST -. t/ •--
UNIT HEATER 1 ll111111 e 2 92019
UNVENTED ROOM HEATER
WATER HEATER '__ .
OTHER g4it DIN-; UF�ARI WEN
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES N] 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 ❑
OWNER'S INSURANCE WAIVER.: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1
CMassachusetts General Laws,and that my signature on this permit application waives this requirement.
.
•`� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ 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
Nz', Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Li
PLUMBER-GASFITTER NAME g7,, °LSc,-, LICENSE# 2.6/02-
SIGNATURE
MP ❑ MGF❑ JP I JGF❑ LPG! ❑ CORPORATION❑#i PARTNERSHIP❑##
/ LLC❑#
COMPANY NAME �J O15on ( I ADDRESS —2 3 5 ,c/kJ y'2 &l &-
CITY ,,J -'�, STATE M4 " ZIP C�23 68 TEL 1)V/ k'l 9 'Y
FAX CELL I
EMAIL
AIOUG GAS II%ISP'ECTION iw({3TE8
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTE
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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FEE: n PERMIT# � �� �� ��
PLAN REVIEW NOTES /