HomeMy WebLinkAboutBLDG-24-286 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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f MA DATE 1�, 7 y
CITY k ' 4G PERMIT#�C -L DC
JOBSITE ADDRESS 7 rfl 71l L-4 3-sr/Nee✓ OWNER'S NAME
GOWNER ADDRESS 5---()2' TEL q?..27_ ./ z FAX_
YRINTR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:
[0.f REPLACEMENT:❑ PLANS SUBMITTED:YES Ar NO❑
APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 45 i i--7 n I-6 f)
BOOSTER
CONVERSION BURNER �—
COOK STOVE /
DIRECT VENT HEATER
DRYER / _
FIREPLACE
FRYOLATOR
FURNACE n,,` , /
GENERATOR
GRILLE
INFRARED HEATER -T.-
LABORATORY COCKS
MAKEUP AIR UNIT _
OVEN
POOL HEATER R�� t
ROOM/SPACE HEATER L
ROOF TOP UNIT
-
TEST _. U5`�r"Y -_- �I
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER U ��<,aq I77[[[
OTHERINSURANCE T���N>L�r�T7n� tN�
I have a current Ifabili insurance policy or its substantial equiva entwhicch COVERAGE
the requirements of MGL Ch.142 YES AI NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY &I, 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 0 AGENT El
I' 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 hapter 142 of the General Laws, 9(.f7 0/
PLUMBER-GASFITTER NAME(IV WeL�r - Cl l LICENSE4 �' Q SIGNATURE
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P n SIGNATURE
MP❑ MGF 0 JP
[ JGF 0 LPGI 0 CORPORATION❑# re 1' 4 PARTNERSHIP
❑# �/r" LLC❑#
COMPA I4AME V.C� D 1 Q `i ADDRESS yi-r.„)q),,
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CITY / /I n 15 STATE Y/1. ZIP 0c/ TEL /rS%� %��
FAX CELL EMAIL 5 1)(J.()1 c.t j 4 �J`
�Oi1G1i GAS SP ON NO E,
TILLS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES R�THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOS