HomeMy WebLinkAboutBLDG-24-388 '°-- h1ASSACHU.SETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM GAS FITTING WORK
CITY Lit /- ter r M rl L'a, MA DATE Z L
7� PER Tf 13LJ6-24-351
JOBSITE ADDRESS///J AQ6r � L- AV OWNER'S NAME
J L OWNER ADDRESS 5 TEL // — -7
TYPE OR FAX�—
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 .7e-S)
PLAtJ..SUBMITTED:YES❑ NO❑
APPLIANCES 7 FLOORS OEM 1 2 3 4 5
BOILER s 7 R 9 10 11 12 13 14
BOOSTER
CONVERSION BURNER
COOK STOVE al
DIRECT VENT HEATER
I 11
DRYER
FIREPLACE
FRYDLATOR
FURNACE -
GENERATOR 1111111
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT E - i I , 2 MN
OVEN •
POOL HEATER I
I
ROOM/SPACE HEATER ' _. .5 1'
ROOF TOP UNIT
TEST 4.5 < rb'Pal .-- .. . I J1LI '�. '_.
UNIT HEATER — �-®_
INVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial eq
uivalent meets the requirements of MGL Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILFTY INSURANCE POLICY lifir 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 0 AGENT❑
SJ
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 pli tion will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the Generalnp� Laws. / / arc' /l
PLUMBER-GASFITTER NAME Ai m✓'.P I� r)cx� LICENSE# / -SIGNATUREtSQ
MP❑ MGF❑ JPn Kt JGF 0 LPGI❑n CORPORATION 0# P rc r" PARTNERSHIP 0# _ LLC❑#
COMPANY LAME I r t eio I '"}"��-{� '?7 ram ,/ 4/ `/J ,q
J iii �"d /,��n ADDRESS lJ Sri �'�{�i„iJ
CITY L �/ /1 I t S STATE MI ZIP e TEL TEL
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FAX CELL // J�=
EMAIL S Ih/l q-Q/-, M cis4PrAo kJ 1%1 4(.(0..N
ItOUGII GAS INSPECT1pN NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No •
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
• FEE: $ PERMIT#
PLAN REVIEW NOTES