HomeMy WebLinkAboutBLDG-23-9561 �" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY A' °LAO U 14 MA DATE PERMITtr•134- -Z 3-9JG i
JOBSITE ADDRESS 3 7 ,q- 'p r d/ -r-- tZt> OWNER'S NAME \ .
GOWNER ADDRESS TEL it TEL FAX
TYPE OR ______________
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:L1J� PLANS SUBMITTED:YES 0 NO 0
APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 ¢ 9 10 11 12 13
BOILER t4
BOOSTER
CONVERSION BURNER
COOK STOVE - I
DIRECT VENT HEATER
DRYER - — 1
FIREPLACE I
FRYOLATOR I
FURNACE
GENERATOR _
GRILLE
INFRARED HEATER -
LABORATORY COCKS - L__
MAKEUP AIR UNIT _
OVEN
POOL HEATER -
ROOM/SPACE HEATER
ROOF TOP UNIT
TE&T - R-[ E H B-
-
UNIT HEATER - -
UNVENTED ROOM HEATER }''
OC1 L.
WATER HEATER `2 202�
OTHER p'
) ����F1�C `Jr BUILD'DV-nF PA RTMFNT
4 By �.
�1
INSURANCE COVERAGE -
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BON
• 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 'th at Pertinent provision of the
�.} Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME V v D� LICENSE# 5- SI�FIA`{URE
MP❑—MGF J�PJ-�GFF'gGGGG'"'H t GI 0 CORPORATION❑# �l7PARTNER�SHIP 0# p C 0#
COMPANY NAME 1110 I'Sr' �/ /�`7- r- ADDRE,SSS�25/1 N 77/V V
CITY y izfr QJ v _ STAT 2 ZIP C/ p j7�/� TEL
FAX CELL ,30 3 3 EMAIL t I I!A Aq JY)at)1 (0 tJ (03
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ROIJ(a� QAti I1�
�PI+ THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
{e5 No
THIS APPLICATION SERVES AS THE PERMIT n
FEE: $ PERMIT
FLAN REVIEW NOTES