HomeMy WebLinkAboutBLDG-22-000919 `� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
��, k�'�_ CITY yhP/Vg.: 7h MA DATE PERMIT# ZZ- - 9
1 1
JOBSITE ADDRESS 96 jG✓ SA r?e tPs OWNERS NAME v Olet' IP41A/
GOWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
PRN El] RESIDENTIAL
CLEARLY NEW:re RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 SSM 1 2 3 4 5 6 7 8 9 10 'I'I 12 1314
_
BOILER ■
BOOSTER
CONVERSION BURNER
COOK STOVE ■
DIRECT VENT HEATER
DRYER `--;
FIREPLACE
FRYOLATOR 1
FURNACE
GENERATOR
_J
GRILLE
111111111
INFRARED HEATER --j
LABORATORY COCKS I
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER ■
ROOF TOP UNIT
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 MGL.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 ❑
• 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.
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 co ance with all perti nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. G
G'GvJ �
PLUMBER-GASFITTER NAME LICENSE# VG SIGNAT
MP X] MGF❑ JP 0JGF IIILPGI ❑r CORPORATION[i]# PARTNERSHIP❑# LLC 11#
COMPANY NAME h l� , v1/414iQk"f J Gti S ADDRESS LJ . /.;!)/4/e ll-
CITY _C. Dvi`/ STATE 4 N • ZIP G t i TEL 77/ , - S
FAX CELL/O-fa,/—4/61.2 EMAIL .firW,ai FiC2‘ . ,/•G1/7
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
•
FEE: $ PERMIT#
PLAN REVIEW NOTES