HomeMy WebLinkAboutBLDG-24-321 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
= v CITY t I yCtt MOu- MA DATE �—c C—D.t/ PERMIT# QLOG-2h- 2t
JOBSITEADJDRESS 5-- iU 1, e OWNERS NAME �O4y3r�e r
G !'Iw OWNER ADDRESS d S a r �$ TEL
TYPE OR FAX—_
PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0"---"----
PLANS SUBMITTED:YES 0 NO
APPLIANCES 7 FLOORS GEM 1 2 3 4 5 F
BOILER 9 10 11 12 13 14
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER _
DRYER
FIREPLACE
FP,YOLATOR
FURNACE
GENERATOR
GRILLE E E u2► D
INFRARED HEATER 0—2—
LABORATORY COCKS D MAKEUP AIR UNIT (' —`
OVEN
POOL HEATER
•UILDI JG DEPARTMENT
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER _ _
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE I have a current liability insurance policy or its substantial equivalent COVERAGE
nt which meets the requirements of MGL Ch.142 YES 0 NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW CI
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
OWNEr S 1t�SU , ' 'WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mae sett ral Laws,and to hat gnature on this permit application waives this requirement.
SIGNA E 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 tru accu a the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in c Ilan c wi ail rtinent rovision of the
LEI
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# 3S'O9 SIGNATURE
MP❑ MGF 0 �JP�GF❑ LPGI 0 CORPORATION 0# PARTNERSHIP❑# LLC❑#
COMPANY NAME II-O?rP (umi ,gyp t"{C'ec j ADDRESS �( 5 "1-- DS�p s --
CITY 1� u r^r 1 J1
y STATE ma ZIP 0,)-(,0/ ,/TEL 2)(/8?C�6
FAX CELL EMAIL P / b�-�G E
y`y�t9..�c M
•
I PAGE FOR.INSPECTOR USE ONLY FINAL'INSPECTION NOTES
OU $i GAS I�i(SPEt, IO 0 �S '
Yes No
THIS APPL.IC,4T(O�d SER�lES A5 THE PEWIT ❑ ❑
•
•
• FEE: a PERMIT#
PLAN REVIEW NOTES