HomeMy WebLinkAboutBLDG-24-285 ` MASSA HUSETTS UNIFOR APPLICATION FOR A PERM T TO PERFORM GAS FITTING WORK
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MA DATE 2 2 PERMIT#ai-o6 Z4 Z 95-
JOBSSITE ADDRESS !i- �r//�� 0 U tgNER'S NAME
GOWNER ADDRESS 'f 1/I TEL
FAX_
TPRIN
YPE TOR OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL L7
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:B-------
PLANS SUBMITTED:YES 0 NO[3"--
APPLIANCES 1 FLOORS-* BEN 1 2 3 A 5 6 y
BOILER 9 10 11 12 13 11
BOOSTER - _
CONVERSION BURNER
COOK STOVE -
DIRECT VENT HEATER y __
DRYER _
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR - ------
GRILLE
INFRARED HEATER �__i
LABORATORY COCKS `P, C t E I V E
MAKEUP AIR UNIT
OVEN
POOL HEATER MAY n f J
ROOM/SPACE HEATER
ROOF TOP UNIT di,r,�Nr.ur eau r wtir
TEST _ .
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
H
1
INSURANCE COVERAGE 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVVERAG CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY d 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
1` 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 all Pertinent provision of the
�' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE#
SIGNATURE
MP-B�GF JPGFGI 0 ORATION❑# PARTNERSHIP❑#
LLC
COMPAY N rL l' ADDRESS � 774-i V
CITY 0✓+ � STATE ZIP TEL pp.56
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FAX CELL EMAIL /f/7/1 'q Y7 a t/Cb 4 C
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UG G INSPEC IO O ES TRIS PAGE FOE.INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATIQ+l SERVES AS THE PERr1IT ❑• ❑
FEE: PERMIT#
PLAN REVIEW NOTES