HomeMy WebLinkAboutBLDG-24-88 NIASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY yGdMOIv/h MA DATE PERMIT# 151D6-2-'1- 0
JOBSITE ADDRESS i- e Y srde- SQeS rt- OWNERS NAME
n
G OWNER ADDRESS .! g t TEL TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL 8 EDUCATIONAL 0 RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:
0------ PLANS SUBMITTED:YES❑ NO 0
APPLIANCES 7 FLOORS-r hSM 1 2 3 4 5 6 7 8 9 10 11 12 13 i
BOILER )4,.. 14
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE —
INFRARED HEATER I �i
LABORATORY COCKS - _
MAKEUP AIR UNIT
OVEN
_ I
POOL HEATER J
ROOM I SPACE HEATER f
ROOF TOP UNIT
UNIT HEATER . .. .. . R � e 1,....F d F..B =
UNVENTED ROOM HEATER _
WATER HEATER _l - t FEB 3-1 2624 - - _
OTHER
- ttetT}C DCIYARTHEfcT i
INSURANCE
I have a current liability insurance policy or its substantial equivalent which COVERAGE meets the requirements of MGL.Ch.142 YES 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
OWNS IN U GE WAIVER:I am that the licensee class riot have the insuu lCe verage required by Chapter 142 of the
Mass hu neral Laws, at signature on this permi tplicati Ivori�es this requirement
.. SIGNAT RE OF OWNER OR AGENT CHECK ONE ONLY: OWNER❑ AGENT ❑
7.1; I hereby certify that all of the details and information I have submitted or entered regarding this application are true d 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 c ' ce with ail Pertinent provision of the
UJ Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTEP,NAME LICENSE# a 33 fa i NATURE
MP❑ MGF❑ JP JGF❑ LPG❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME "�- 1? a C ADDRESS 7 S>,--f` ?CCe pL-- c —
CITY <<Fyvv^r 0 STATE MoN, ZIP 0.)470/ TEL
FAX CELL 77t/ g?r; 6Y6(EMAIL
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $ PERMIT ft
PLAN REVIEW NOTES