HomeMy WebLinkAboutBLDG-24-526 (4,IV (-�UI151�r S
_-- MASSACHUSETTS UNIFORM APPLICATION FOR AFE- IT TO PERFORM GAS FITTING WORK
CITY bl-kiV►�/�Urt ' ` MA DATE lit,-
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_ �J v' PERMIT. Bf (0- 4- S2G
JOBSITE ADDRESS 2 Jii
I r� �-�."r`-' ' � � ail T OWNERS NAME P6JG �-,
OWNER ADDRESS TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW;❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES El Np
APPLIANCES 1 FLOORS 65M 1 2 3 4 5 6 7 8 9 to 11 12 1 y
BOILER
BOOSTER _
CONVERSION BURNEP,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR - -
FURNACE
GENERATOR - - _ J
GRILLE J
INFRARED HEATER 1
LABORATORY COCKS
OMAK G EUP AIR UNIT R-t '' 11,, EID "
Y_.._
POOL HEATER
ROOM I SPACE HEATER sEP 0 G[0[4
ROOF TOP UNIT
TEST _. UI NU DE F+q 1r '
_ __ MENT
UNIT HEATER ._ _ "_... „�'„Un ---.. __
UNVENTED ROOM HEATER _
WATER HEATER
OTa�Ry� '
i``�e-rgo,4 el-Cie T2 -
INSUNCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU.Ch.142 YES NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ 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 am to 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 wi Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
1.1j
PLUMBER-54SFITTER NAME LICENSE# / SIGNATURE
MP vIGF42 JP JGF LPG-❑ CORPORATION❑# PART 0# LLC go#
COMPANY I ME ADDRESS E77+!V /
CITY U L O STATE M' ZIP O`
/ *�
� TEL
FAX CELL S v)120 Q`1 EMAIL o'v6
&q kik „cooet
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FILIAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 1 I I )
FEE: $ PERMIT #
FLAN REVIEW NOTES