HomeMy WebLinkAboutBLDG-15-004866 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: 41Fs% MA. DATE 07- /S PERMIT#I b'/6-�V
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JOBSITE ADDRESS: /et, M A ?ST OWNER'S NAME: ,erx4S5- S'+oc c
GOWNER ADDRESS: 3/4 ot,a.a TEL: FAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL ja EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:. PLANS SUBMITTED: YES❑ NOS
APPLIANCES1. FLOOR--• Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
VI INFRARED HEATER
_LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
- M/SPACE HEATER
J R00 TOP UNIT
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Mai MEATE"TER TE
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BUILDING !4.0ht41•_ t\ INSURANCE COVERAGE
•-•• policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES fff NO ❑
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY E. 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 compliance with all Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: - """ea Ci& v 6e../00+.J LICENSE#o? s-o #S;lahRE---
COMPANY NAME: a.JCJ.o Q 210 A d ;,J6 ADDRESS: ?i 30 X 4ti p p rj5'
CITY: ?Ed.it O-‘,ic t STATE: ZIP: ad-Vie FAX: <I f•, 9 3-d S T
TEL: `/Ol-'719-,SSA CELL: gel- Ws---- ?)' EMAIL: 44i6.. ,2 Pk#4,6,rG 7GZ6t r s,1 . fog
MASTER❑ JOURNEYMAN® LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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• -ICENSE NUMBER EXPIRATION DATE SERIAL NUMBE.L:.1
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