HomeMy WebLinkAboutBLDG-24-386 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
19 CITY 1,?/f'`1 '�(,'12.I/ 0016 MA DATE 01/Y'JC C,/ 2 ) PERMIT#01°G-2't SY4
JOBSITE ADDRESS 7z., Lebo 15 'RC OWNER'S NAME Ai4.C7GtiPr'- 41,49R4L
G OWNER ADDRESS 5.4NA e TEL
TYPE OR FAX��
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION:A REPLACEMENT:0
PLANS SUBMITTED:YES 0 NO 0
APPLIANCES 7 FLOORS-' Sal 1 2 3 4 5 6 7 8 9 10 11 12 13 T
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYO ATOR
FURNACE
GENERATOR T R E CE-1 V F- I_GRILLE r
INFRARED HEATER -I
LABORATORY COCKS t JOIN ;on
MAKEUP AIR UNIT I 7
OVEN -I CUi DIN(IL,_ j4lf LNT
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER •
UNVENTED ROOM HEATER
WATER HEATER {
OTHER -?e/176)�/C p 5-1-wit, A fr' i' V
Crf ofF 6fr, " Id 4i,4sr"r1 erI_
INSU
I have a current liability insurance policy or its substantial equivalent which COVERAGECE meets the requirements of MGL Ch.142 YES aNO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L.
OTHER TYPE INDEMNITY ❑ 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 0 AGENT 0
i•s 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 LICENSE# SIGNATURE
MP❑ MGF❑ JP.21 JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME D,1n 1S I:_Ar Li, r 1 N ADDRESS /k 2 fit(.4 .SAK,i'aiiL Xi XX
CITY S,4Iz/pa''CN STATE hi.;( ZIP O;C-63 TEL S6)(i R}/ y
FAX CELLS ,(S/ EMAIL 5 v ssy fl - onob,1Le 01' l�l(o7
.4SD,00
O GH Ga SPECTIOI�I 15
TRLS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: $ PERMIT ti
PLAN REVIEW NOTES