HomeMy WebLinkAboutBLDG-24-117 MASSAC USETTS UNIFORM APPLICATION FOR A ER TO PERFORM GAS FITTING WORK
_CITY MADATE /_` PEKNIT#gtI) ZH 117
JOBSTE ADDRESS 7/q.I ff"?5 Z.--q '' /
i OWNER'S NAME J e„if.) / W:luiLaers
OWNER ADDRESS ?-0 S Pa.rO ,1 DFTELcI2z--/ & A.X
TYPE OR ---
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:�71 RENOVATION:❑ REPLACEMENT:❑
1� PLANS SUBMITTED:YES NS NO❑
APPLIANCES 1 FLOORS-. BEM 1 2 3 4 5 6 7 8 9 10 11 12 13 11-1 BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT'\/ENT HEATER
DRYER
FIREPLACE
FRYOLATOR —OP
FURNACE
GENERATOR
GRILLE
INFRARED HEATER -
LABORATORY COCKS
MAKEUP AIR UNIT •
Y _
OVEN
POOL HEATER
ROOM/SPACE HEATER 1 -FEB-1 6
ROOF TOP UNIT I i
TEST _ I
UNITT
LINVENTED 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 El NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details end 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 CodedA and Chapter 142/Ioff the General Laws.
PLUMBER-GASFITTERNAM,/�lU r/ ► ,(t' a"L /9�r1
�F ' � d[Y� LhC1ENSE/f�r SIGNATURE
MP❑ MGF❑ /JPP®CA)
❑ LPGI❑ CORPORATION❑# / ('or PARTNERSHIP[)]* �r/A�.pLLC❑#
COMPANY
INAME
,,U V I(-— r/ ^ ',7 ADDRESS 37 f 'c i % /71 `p�I/,(
CITY / 6 i1 /_S STATE/"t/ ZIP e�(/�G{_ TEL 77 y 01Q Ji z
•
FAX CELL EMAIL e/ .Mr' S ,Ire
r r
gOUGki 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
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