HomeMy WebLinkAboutBLDG-24-421 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY
GrN/� MA DATE /�j��) PERMIT#ISCuG-Zh—yzt
JOBSITEADDRESS 12 PC I1(,c.K 144;1 _A "ci OWNER'S N./WE 4r
GOWNER ADDRESS I Q.. PC2110 ',k R;p 1d• TEL C,.r> q6 35
TYPE OR `A7b U —2J
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
210
CLEARLY NEW RENOVATION:❑ REPLACEMENT:
PLANS SUBMITTED: YES❑ NO❑
APPLIANCES Z FLOORS BEN 1 2 3 4 5 6 1
BOILER 9 _ to it 12 13
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER --it
FIREPLACE --_____7
FRYOLATOR I
FURNACE [
GENERATOR
GRILLE
INFRARED HEATER = _
LABORATORY COCKS
MAKEUP AIR UNIT —�
OVEN v 1
POOL HEATER /� j
ROOM/SPACE HEATER 1
ROOF TOP UNIT R E C-E �—
TEST .. f__ _ B
UNIT HEATER —
1 --
024-
1.INVENTED ROOM HEATER �5
WATER HEATER ■
OTHER Hy
- - Buie oINra�L�>AR
INSURANCE COVERAGE
I have a current Iiabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES al NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IN 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 0
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 alt.Pertinent provision of the
LI} Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME yyyyy� fl� �l_,
�"��[/) 80(m/Yet✓1 LICENSE# 3a2c7 SIGNATURE
MP D MGF 0 JP 4 JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIPr 0# tic❑#
COMPANY NAME /7A .A/I 49/0/4b��,/Yj ADDRESS Pa /jy( 1�7,(?
CITY (.0.-SEylcttri STATES 4 4 ZIP 0a.651 TEL 715t-S yy-6577
FAX CELL EMAIL
OUG$i GAS;,ucvE d"'7'](lN N0TES
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
• FEE: PERMIT# •
PLAN REVIEW NOTES