HomeMy WebLinkAboutBLDG-24-393 —mom"= MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING'WORK
II CITY 4130704- Yl MA DATE 6 a a 4 l
PERMIT# ,1_y—
JOBSITE ADDRESS 6a DR/Y OS- red C r f ck OWNER'S NAME /ADD n
GOWNER ADDRESS6a DQlrlflr/- ree Crr'c(e TEKS0t3Jg l-kl4}- FAX
TYPE OR --�
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 03.
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:
PLANS SUBMITTED:YES 0 NO❑
APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7
BOILER 9 10 11 12 13 14
BOOSTER
CONVERSION BURNER
COOK STOVE
/
DIRECT VENT HEATER
DRYER - --
FIREPLACE i
FRYOLATOR
FURNACE
GENERATOR -
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN _ _
POOL HEATER
ROOM I SPACE HEATER --
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE I have a current liabili insurance policy or its substantial equivalent COVERAGE nt which meets the requirements of MGL Ch.142 YES 2 NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY 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.
'� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER❑ 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 complian th all PerJtnent provision of tie
J Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `-� S
PLUMBER-GASFITTERNAMEGKt-ke1,Sej-F LICENSE 4,467ty V SIGNATRE
MP 0 MGF❑ JP® JGF 0 LPGI 0 CORPORATION❑# u PARTNERSHIP❑# LLC 0#
COMPANY NAME 6rf$oeyc &lir*ce4vrcc ADDRESS r( 5-P"ire4. 4-1¢11 L
CITY bi`YA rTho,11, /�
STATE PIA ZIP Od673 TELi p 7)g'- ' I y
FAX CE(51?) fl -/'t 3 4 I
EMAIL SG re 8(rq Q v 0®.L9 yy1
ROI1GIi G 'NSF EGTIO O ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
•
•
K•