HomeMy WebLinkAboutBLDG-20-002519 `. IIIIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Itir:Wirf CITY/cv yet•',176, L1 MA DATE /m/ ///f PERMIT# la CL'_af�sj
JOBSITE ADDRESS 42 -/ Ke f^/` NAME TTE62. ,�,l_i-
`� �ov/�f OWNERS
OWNER ADDRESS TELeC'3—&Z- 7715' FAX
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TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL 2/
CLEARLY NEW;❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: ,_ .
❑ YES❑ NO❑
APPLIANCES 1 FLOORS—+ BEN 1 2 3 4 5 6 7 g
BOILER 9 10 li 12 I� 1=
BOOSTER
CONVERSION BURNER '
COOK STOVE _
DIRECT VENT HEATER
DRYER 1 . _ 1
FIREPLACE --�
I
FRYOLATOR I
FURNACE _J
GENERATOR ___________I
GRILLE
INFRARED HEATER -I
LABORATORY COCKS i 5-'i . 1 i '--1MAKEUP AIR UNITJ ' __1
OVEN
POOL HEATER • i tin 3
ttl ROOM I SPACE HEATER t _ROOF TOP UNIT
TESTat_ It_DIN,,, . •r• - . . --._—
. . ... . .. �3Y
UNIT HEATER
INVENTED ROOM HEATER
WATER HEATER _r____
OTHER
_ ..
_______
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [210 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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LIABILITY INSURANCE POLICY El 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
• SIGNATURE OF OWNER OR AGENT
'i, I hereby certify that all of the details and information I have submitted or entered regarding this application are e 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 liance with all P ent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L�L�
PLUMBER-GASFITTER NAME LICENSE#23/7/o SIGNATURE
MP ❑ MGF❑ JP ❑ JGF Z LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME e•(ooA P/M 4y- --f I /�ADDRESS 7O r /Y' y �-
CITY frrr S LL O' / ,,f STATEfr4• ZIP 0z(o / TEL,c0 " y�D-OD/a
FAX CELL EMAILD C (0K P ti L? yalGU rC l ,
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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PERMIT# CY s°-21
FEE: � /�
PLAN REVIEW NOTES /I // 7