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HomeMy WebLinkAboutBLDG-24-514 IJMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY //Clem°J ' MA DATE 8-y a� PERMIT QLilG-2 2- 51 T JOBSITEADDRESS aci chI4e s s cef O1hQVER'SN.AME G GKlecO OWNER ADDRESS a 9 GhRle,ies 5 ree f" TEL(08)17 i Lt)6a FAX_ _ TYPE OR OCCUPANCY TYPE COMMERCIAL E PRINT ❑ EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0 I APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 9 9 10 11 12 13 tE I BOILER BOOSTER CONVERSION BURIVEP, COOK STOVE I - - DIRECT VENT HEATER I DRYER FIREPLACE FRYOLATOR - - FURNACE GENERATOR • _ GRILLE INFRARED HEATER LABORATORY COCKS - 1 MAKEUP AIR UNIT - _y OVEN i POOL HEATER • ROOM/SPACE HEATER I I 1 ROOF TOP UNIT - TEST I UNIT HEATER "' UNVENTED ROOM HEATERI 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 COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY ❑ BOND 0 • OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the I Massachusetts General Laws,and that my signature on this permit application waives this requirement. ' } CHECK ONE ONLY: OWNER 0 AGENT 0 --. SIGNATURE OF OWNER OR AGENT 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 Perth nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. tt.PLUMBER-GASFITTER NAME b4aeySej . LICENSE#x-py SIG RE MP 0 MGF❑ JP© JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC❑#DBA COMPANY NAME(reE.t"(Srefft&Awl SetwcC ADDRESS 40 5 Pet Ai elf Li}/It CITY (A.)' Yet into An STATE PIA ZIP 0b-673 T(S"(')71g-I(t?l( FAX CELL)"""143 4 EMAIL Se,(Ft8 res y4-kOI,co(4 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes K THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT ft PLAN REVIEW NOTES