HomeMy WebLinkAboutBLDG-20-003826 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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MA DATE 1 cl COLD PERMIT#7:.��`��3�o�O
JOBSITE ADDRESS I(9�1 [flt1) f -C1-\ 1 - OWNERS NAME t hL Lo
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OWNER ADDRESS UiJLY
— / TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0
APPLIANCES 2 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 it
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER 6 f t?
LABORATORY COCKS �•/
•
MAKEUP AIR UNIT
OVEN POOL
,yr FL
P HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST /.
UNIT HEATER —
UNVENTED ROOM HEATER •
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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.
CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are and o the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c nce ertinent provision of the
Li I Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAMEF K—C F1 E e C_ LICENSE# uaDLZ_ SIGNATURE
MP❑ MGF 0 JP JGF❑ LPGI❑ CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME 'bE<ZELCt)PL_vMBLV—rJ , ADDRESS P• • Bo\ 12-4B
CITY STATE/"/A ZIP OZ64-1 TEL svEs Z9z 7L`-1j
FAX CELL EMAIL LEA-1_E-e—C1�E1E-f`CC AOC•to!✓)
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"TESTHIS PAGE FOR INSPECTOR IJSE ONLY FINAL INSPECTION NOTES
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THIS APPLICATION SERVES AS THE PERMIT f
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-° /74 cp20 FEE: $ PERMIT #
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PLAN REVIEW NOTES