HomeMy WebLinkAboutBLDG-24-403 = MASSACHUSETTS UNIFORM APPLICATION FOR A P RM TO PERFORM GAS FITTING WORK
CITY r
MA DATE PERMIT
# Z Z�17
JOBSITE ADDRESS OWNER'S NAME_//1 1.L/i� l� 7
G OVJIJER ADDRESS TEL FAX
TYPE OR �_
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:'
PLANS SUBMITTED:YES k NO 0
APPLIANCES-3 FLOORS—. SSM 1 2 3 4 5 6 5 9 10 11 12 13
OILER
BOOSTER
CONVERSION
lir
CONVERSION BURIJEP.
COOK STOVE 2—
DIRECT VENT HEATER
DRYER
FIREPLACE —
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN �R �. ''_ ' _ —
POOL HEATER c
ROOM I SPACE HEATER G JUL 0 22124
ROOF TOP UNIT
TEST .. 4
UNIT HEATER _ aW--D r,v i E v+. E 7
LINVENTED ROOM HEATER �=--
WATER HEATER _
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESX NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY A 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 12
`j 4, 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 app• .Il be I ompliance with all Pertinent provision of the
�} Massachusetts State Plumbing Code andn Chapter 142 of thdGeneral Laws. /� / 22 PLUMBER-GASFITTER NAME M l I/�0j��T t � !LI ENSE#
SIGNATURES
MP❑ MGF❑ JP a JGF 0 LPGI CORPORATION❑#Prof) PARTNERS IP❑#/ LLC❑#
COMPANYr NAME ,�/ )(Qp�(�' � ADDRESS 3 lc1/[tom[(// (�(�e
CITY l"--1 CG T AA 6)u,j STATE AO'ZIP 02-6 3 TEL // 47/e q/ 2_
FAXCELL EMAIL •/1.‘ n
CJ�f �Xo® / rrn
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t�t,3UGkl GAS I1'ti'SPIi C 0_ ES •
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATIO SERIES A�THE PERi1dIT ❑•
❑
FEE: PERMIT#
PLAN REVIEW NOTES