HomeMy WebLinkAboutBLDG-24-181 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY/401/01/tYGPt MA DATE 3-i9-aC-2ay PERMIT#B4-b(-,.. V-/g/
JOBSITE ADDRESS 5:3 ft
OWNER'S N.4MEDIrn',nr�' nr7
GOWNER ADDRESS/5J,U, 1etaC J /eeft rear TEL v FAY_
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 ED
UCATIONAL DUCATIONAL 0 RESIDENTIAL IlliA
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:
PLAfJ..SUBMITTED:YES 0 NO
IX
APPLIANCES T FLOORS-, ESM 1 2 3 4 5 5
BOILER 9 10 11 12 1_ t_
BOOSTER
CONVERSION BURNER,
COOK STOVE �_
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT -
OVEN
POOL HEATER -__
L
ROOM I SPACE HEATER MAR
ROOF TOP UNIT • e�'1t 2
0-
TEST ..
UNIT HEATER
UNVENTED ROOM HEATER "Y AKrnn
WATER HEATER l Nr
OTH R
rePA«. /i'ff'&- -irojk s,`!! / -
I have a current liability insurance policy or its substantial equivalent whichINSURANCE COVERAGE
the requirements of MGL Ch.142 YES I NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
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 ❑ AGENT❑
tiI hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate tote best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be In compliance with at P nent provision of the
Q.), Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 2
PLUMBER-GASFITTER NAME LICENSE#2197 SIGNATURE
MP❑ MGF 0 //JP y� JGF 0 LPGI❑ CORPORATION❑# yPARTNERSHI # LLC 0#
COMPANY MAME/8,1 1qun, � . 2 R� ADDRESS / �l,�j ApL- �7
CITY/�0'r�J,!1, J Y STATE R4 ZIP v y5 `J n/ TEL��x'2/6-5f
FAX CELL EMAIL /G'IfJu/s 1'�a`,±1 o.1.Com
/Oinr°JttS5/Ia_ 4Ae)i 14;1• C0/71
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