HomeMy WebLinkAboutBLDG-23-9739 # B MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY \/A-21O Ji I' MA DATE / c�Q-9 PERMIT�'6C-uG-'L?-9'739
JOBSITE ADDRESS sy3 �y1-C t t g(6. OWNER'S NAME tf 1G >1
OWNER ADDRESS TEL7 7 .Lf V'Q a�
TYPE
OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:—DU
PLANS SUBMITTED:YES❑ NO❑
APPLIANCES 7 FLOORS-. BEM 1 2 3 4 5 6 7 8 9 10 11 12 13 lA
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE V— .f TrzL__
GENERATOR
GRILLE
INFRARED HEATER —�
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER -
ROOM lSPACE HEATER
ROOF TOP UNIT -
TEST ...
UNIT HEATER
UNVENTED 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 LrJ N0❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E 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.
CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
c4, 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
s'' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP 0 MGF❑ JP❑ JGFJG�I�J LPGII 0t CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAMEr AV 16 r E b'/T/L �A/ • ADDRESS o2 /'¢f3y4J, (
CIT Y Y STATE ZIP O o9r�?,�� TE�7L �l,qv$ / '�Z16e
FAX CELL 7$I -'al• <6?is EMAIL it-Put/7r 46& E i�lC(lJM*iLc-l-
ROUGJI GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes N9
THIS APPLICATION SERVES AS THE PERMIT ❑•
❑
•
FEE: $ PERMIT#
PLAN REVIEW NOTES