HomeMy WebLinkAboutBLDG-24-503 = MASSACHUSETTS UNIFORM APPLICATION FOR A ERMIT TO PERFORM GAS FITTING WORK
____;-- CITY
� MA DATE 2 PERM # Q Lb 6 Z`I- sG3
JOBSITE ADDRESS 7�/t�.QrL 7' (2-al I rr--�4. OWNER'S ' /I d/ ' Cj 0,11
G OWNER ADDRESS 7Y TEL 1qy-
FA
TYPE OR / / Y,—_
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL K
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:
PLANS SUBMITTED:YES❑ NO Qg
APPLIANCES 7 FLOORS-. hEM I 2 3 4 5 6 8 y
BOILER to 11 12 13 14
BOOSTER
CONVERSION BURNER
COOK STOVE —
1—
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE I
GENERATOR
GRILLE
-
INFRARED HEATER -
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER - ' ? E Eril yr F _
ROOM(SPACE HEATER I
ROOF TOP UNIT j I G'-'D 20/4
TEST `
UNIT HEATER l �._.
UNVENTED ROOM HEATER i aua NG° AK rneNi _
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liabili 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 it
LIABILITY INSURANCE POLICY in 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
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General ws.
PLUMBER-GASFITTER NAME! '1 ,14 t°L M�(`/IXQ LI�"0
LI ENSE#p Si, A�141
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MP❑ MGF 0 /�JPP� JGF❑ LPGI 0 CORPORATION❑# Pro I-PARTNERSHIP❑# U"C 0#
COMPANY NA E 1 • \ Cr C/ko P-H i
!T R OM ADDRESS 7�/-��n idn „4/Q.�„� •
CITY l lI f S STATE v v ZIP 6 �jt(f / TEL '7✓ `ria qq
FAX CELL �� /J��
EMAIL
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$OUGh GAS HygPEC�ION O EIS
'PHIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPL ICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES