HomeMy WebLinkAboutBLDG-24-391 1�/� ril'3. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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'`— CITY Yet Al CryTH IM, DATE 6/a7/,T n y PERMIT#3L. G a?N y/
JOBSITE ADDRESS 111//]C 1-1r 1
22 OWNER'S NAME\ffM IC i Sull u)Al L
G OWNER ADDRESS 5AAI L TEL 6�776 L6 yU FAX
TYPE OR —�
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:
REPLACEMENT:0 PLANS SUBMITTED YES❑ NO
APPLIANCES 1 FLOORS-. BSM I 2 3 1 5 6 7 8 9 10 11 12 13 10
BOILER
BOOSTER
CONVERSION BURNER __,
COOK STOVE t
DIRECT VENT HEATER
DRYER r
FIREPLACE
FRYOLATOR I
GRILLEFURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS -
MAKEUP AIR UNIT
OVEN _
POOL HEATER _ '. �L-C {V-E n
ROOM/SPACE HEATER f
ROOF TOP UNIT `
TEST - N 6 ��I
UNIT HEATER
UNVENTED ROOM HEATER 3`,,ni Nr u=PA RIM ENl -
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent
t meets the requirements of MGL Ch.142 YES[>�ND
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 0
LIABILITY INSURANCE POLICY.' OTHER TYPE INDEMNITY D BOND ❑
OWNER'S INSURANCE WAIVER:I are 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 El AGENT 0
• 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 pernk issued for this application will be in corn fiance with ertinent provision of the
LE/ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �LCCC���[[ff¢¢//d
PLUMBER-GASFITTER NAME LICENSE#.2f/795- SIGNATURE
MP❑ MGF 0 JPIVA JGF❑-LPGI❑ CORPORATION 0# PARTNERSHIP 0#'` LLC❑#
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COMPANY NAME (107t9 5 l/ /e ADDRESS 7 G/ult 1�Ck F+Q.
CITY OGofiht-hale STATE /14 ti ZIP p(226 3)' TEL 5O6 665 476a5
FAX CELL 46 6 SS'' $ EMAIL
ItOUGTI GAS iI*ISFE 0IY NI3TiE5
TIES PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: v PERMIT#
PLAN REVIEW NOTES
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