HomeMy WebLinkAboutBLDG-24-387 1, MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM GAS FITTING WORK
rj CITY /Grtvtp;-,t"h MA DATE 2J 2 I RZlJ6-zh-3y7
PERMIT#
JOBSITE ADDRESS I(a I r-G1
T OWNER'S NAME L l /5 _-q
OWNER ADDRESS SacV3 Ou4 64c. TEL 77926$ I 6 FAX
TYPE OR —�
PRINT OCCUPANCY TYPE COMMERCIAL tg. EDUCATIONAL ❑ RESIDENTIAL❑
CLEARLY NEW:Vi RENOVATION:0 REPLACEMENT:0 PLANS
SUBMITTED:YES 0 NO❑
APPLIANCES FLOORS-- BEM 1 2 3 4 5 6 7 s 9 10 11 12 1
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS k L �7 D
MAKEUP AIR UNIT '--
OVEN
POOL HEATER [ _ - r H
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 3-1!L D rx,u_rH n f me-RI ,
.. .. ... _ _ iY_ _ ___ _
UNIT HEATER T
UNVENTED ROOM HEATER
WATER HEATER
OTHER
r, .od.n Valve o,s I
ma,n la$ 'krne_ - -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES liij,NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ❑
LIABILITY INSURANCE POLICY' OTHER TYPE INDEMNITY 0 BOND ❑
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.
J SIGNATURE OF OWNER,OR AGENT CHECK ONE ONLY: OWNER❑ 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 an e ne
e with at Pnt provision of the
LIJ
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. GAY
PLUMBER-GASFITTER NAME urGf
LICENSE# 2 Lc.?
Li SIGNATURE
MP S MGF 0 JP 0 JGF 0 LPGI 0 CORPORATION❑#
_ PARTNERSHIP El# LLC❑#
COMPANY NAME �Qtyi- 1- PLCNiE,EC P C R.O 2-
p �1 ADDRESS J
p
CITY_ M rT v"ncS 1 G t STATE / ' ZIP CG.±1 TEL SO& p l% 2L 03
FAX CELL
EMAIL ✓'e ClOwe. e p1 ,r.ber Co,.,
OUGIi_GAS II1fSI'�'dTIOI�(Nd3_TiES
THIS PAGE FOR.INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: $ PERMIT#
PLAN REVIEW NOTES