HomeMy WebLinkAboutBLDG-24-534 . -n
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY --PA cnr6v,l I*, DATE 9/t0/-2�
IP' PERMIT# QL______
JOBSITE ADDRESS l'3 3 Mw7 E\.evsJ V.•'Cure c OWNER'S NAME E C.r0 1, G 0,4RA e-
93 AfravJ 'Or CGfl)
OWNER ADDRESS Sc i�vwlo /v16 TEL WIS"64 S O FAX
TYPE OR
PINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NE RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0
APPLIANCES 7 FLOORS BSM 1 2 3 a 5 6 0 9 10 11 12 13
BOILER 1E
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER J
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR -
GRILLE
INFRARED HEATER -� E C F. I F�
LABORATORY COCKS
MAKEUP AIR UNIT shell
OVEN
POOL HEATER •
ROOMISPACEHEATER arri 2NGPJEPA TnnEnr
ROOF TOP UNIT BY —-
TEST -.
UNIT HEATER
UN VENTED ROOM HEATER •
WATER HEATER K
OTHER Ot- 4e 0)0..)
.JA.+,e, S-4Ov-it
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NI NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY s, OTHER TYPE INDEMNITY 0 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.
CHECK ONE ONLY: OWNER 0 AGENT 0
ti SIGNATURE OF OWNER OR AGENT
�ti+ 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
yt Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Q_AM
PLUMBER-GASFITTER NAME R a�er Y o..e-rr e 3
s1 LICENSE# l3 8 3 SIGNATURE
MP xi, MGF 0 JP 0 JGF❑ LPGI❑ CORPORATION❑4 PARTNERSHIP 0# LLC❑#
COMPANY NAME 1),S•A, C$..CI M-t.c --c..N I.-.e.U ADDRESS —1- ko,,,,. 1,e„ Y2a
CITY G(?h3 s konl STATE Q\ ZIP O _C)1 b TEL 1
FAX Cho, `t S'6-1l9-St EMAIL crn1.0)4..u v4,V11- o,_ c•3 rrv.c,.\„..CM ryV‘
ROUGH GAS INSFE' cTIO N NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOSES
`f e5 No
THIS APPLICATION SERVES AS THE PERMIT [—
FEE: $ PERMIT ft
FLAN REVIEW NOTES