HomeMy WebLinkAboutBLDG-24-254- Y°� - mASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY Y4rrv.ovkl,
n MA DATE O 7 /l Z7 PER�MyIfT# Ll7C ay oJS
JOBSITE ADDRESS Y tC`:s o,r' V.s-t - OWNER'S NAME i/C�CIR' _____
GOWNER ADDRESS TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT
PLAN..SUBMITTED: YES❑ NO❑
APPLIANCES Z FLOORS-. 5SN 1 2 3 4 5 6 7 3 9 10 11 12 13 1.4
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
--
DIRECT VENT HEATER
DRYER --
FIREPLACE
FRYOLATOR -
FURNACE t =
GENERATOR
GRILLE
INFRARED HEATER
E LABORATORY COCKS
O MAKEUP AIR UNIT - •
' OVEN
j POOL HEATER
6 ROOM I SPACE HEATER
' ROOF TOP UNIT
TEST al
UNIT HEATER
--
aUNVENTED ROOM HEATER j r4 '
WATER HEATER7 1
OTHER O I
S ��- _ 'Dtp RTM� -
3 INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGI_Ch.142 YES y41 NO 0
* I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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LIABILITY INSURANCE POLICY li OTHER TYPE INDEMNITY 0 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
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
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.
PLUMBER-GASFITTER NAME E-4.•.L �cCc d
LICENSE# l`)-19-3-mT'l SIGNATURE
MPin MGFX) JP 0 JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP 0# U_C❑#
COMPANY NAME
ADDRESS
CITY 1C r75':,nc1 tie ATE (k• ZIP C1g--13 t TEL
FAX CELL SS 9'-(2.-,'9-6(.,6 L. EMAIL
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
�tOuj S INSFEC i IOrs ES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
• FEE: a PERMIT#
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PLAN REVIEW NOIES
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