HomeMy WebLinkAboutBLDG-23-9711 ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY _n__:'' I—Gr r—�1L�ZL L_1 �hA DATE I C�/23 PERMIT#&/X', ? JOBSITE ADDRESS OWNER'S NAME Ir5-e99, YZI
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G OWNER ADDRESS /C'77 ef-P,` D�TEL 76o 60,o FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL V EDUCATIONAL ❑ RESIDENTIAL 0
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO'ca
APPLIANCES 7 FLOORS BSM 1 2 3 q 5 6 7 8 9 10 11 12 13 1"
BOILER
BOOSTER
CONVERSION BURNER.
COOK STOVE -
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYDLATOR
FURNACE
GENERATOR „ d V E D-
GRILLE ---
INFRARED HEATER �LJ Ov art
LABORATORY COCKS UV3 U LU
MAKEUP AIR UNIT -
OVEN POOL HEATER _, N, u_EPA TMEVT
ROOM I SPACE HEATER - _ -T— —
ROOF TOP UNIT
TEST
UNIT HEATER
INVENTED ROOM HEATER
WATER HEATER
OTHER
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND D
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 11AGENT 0
•-, 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /'G/,�"-/ /\ ��
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PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP❑ MGF❑ JP 0 JGF 0 LPGI❑ , CORPORATIONOR ❑4 PARTNERSHIP❑# LLC❑'_#/J
COMPANY NAME 1 ('i pQ r7 j�r-7' ADDRESS / �c 11`�k-✓'1 A—'-`�
CITY ('^�c7✓):�/ S STATE ZIP 2/e(� TEL 7 7'/ O�Q I(7�
FAX ` CELL EMAIL � ®/ - (E.',
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AOUGI3 GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT it
PLAN REVIEW NOTES
1