HomeMy WebLinkAboutBLDG-23-9521 MASSACHUSETTS UNIFOR
M APPLICATION FOR A PE ET TO PERFORM GAS FITTING WORK
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CITY � Dc/� /Ict; C.-MA DATE PERMIT# l c JG-2-3
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JOBSITE ADDRESS 7 /32 4/5 1-,7 l cone' OWNER'S NAME -e &de
G OWNER ADDRESS // L 5/j AY
57 OTEL 7
TYPEOR __�
PRINTOCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
CLEARLY ❑ R�=
RESIDENTIAL[rEr
NEW:�, RENOVATION:❑ REPLACEMENT:❑
PLANS SUBMITTED:YES 0 NO 0
APPLIANCES Z FLOORS-4 051A 1 2 3 -1 5
BOILER s 7 e 9 to 11 12 13
BOOSTER
CONVERSION BURNER ________
COOK STOVE
DIRECT VENT HEATER -
DRYER -
FIREPLACE
FRYOLATOR I —I
FURNACE —___J
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT •
OVEN
POOL HEATER
ROOM I SPACE HEATER 1 D
ROOF TOP UNIT 4
TEST _
UNIT HEATER
INVENTED ROOM HEATER • - `EP-2 2023 I -
WATER HEATER , BITILDINCWLPARTM Nr I OTHER _ 1
uY_ _
17-1
INSURANCE
I have a current liability insurance policy or its substantial equivalent COVERAGE
which meets the requirements of MGL.Ch.142 YES NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY pi. OTHER TYPE INDEMNITY ❑ 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.
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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��/ `
L` ^ ( \�J PLUMBER-GASFITTERLUMBER-GASFITTERNAMB `�`kr1-16pLAc7jrL LICENSE# SIGNATURE
MP 0 MGF❑ JP❑ JGF❑ LPGI 0 CORPORATION❑# p,O P PARTNERSHIP❑# // LLC❑#
COMPANY N MC 'r_ , ( ) p t—r S,- ADDRESS 7 Fr,--7,Ga-/.? v/ `-
CITY / C,/4l S. STATE ZI1,0 TEL d/ TEL 7)7 Yte) 7/ Lz
FAX CELL EMAIL S n 3 ref•/Lr c/�r 11
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I1(SPEC-T'I�P� I3 ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
T1GIi GAS f �1
Yes NQ
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
• FEE: $ PERMIT fI
PLAN REVIEW NOTES