HomeMy WebLinkAboutBLDG-20-002799 MASSACHUSETTS LP (FORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`` sN' CITY /0/'/'j0C� C MA DATE / /3 PERMIT*� 4���1�/
�� 2456 l5 OWNERS p
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JOB E ADDRESS / CItiIdER'S N.M
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OWNER ADDRESS TEL
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:Z'''''.RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 27
APPLIANCES a FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 •11 12 13 1
BOILER
BOOSTER _
CONVERSION BURNER,
COOK STOVE , _
DIRECT VENT HEATER I
DRYER —�
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE __� ir:r_r___
' gINFRARED HEATER —1LABORATORY COCKS I1 MAKEUP AIR UNIT ` 1 ;
OVEN t
POOL HEATER .
ROOM ISPACE HEATER.
ROOF TOP UNIT
TEST .. _.
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER
OTHER
—1 \
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MMMIGL.Ch.142 YES ISO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ 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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
•`` SIGNATURE OF OWNER OR AGENT
"1• I hereby certify that all of the details and information I have submitted or entered regarding this application are tr and accurate to the be, of my knowledge
`k- and that all plumbing work and installations performed under the permit issued for this application will be in co pii ce with all Pertinen ovisi of the
�_I Massachusetts State Plumbing Code a11nd��Chapter 142 of the Gener Laws. ,f l
PLUMBER-GASFITTER NAME�CJ'irL C;O l>C LICENSE#/ook SIGN&E (((
MP I MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION # PARTNERSHIP❑# LLC24 y/473
COMPANY NAME 4:-7'v, 01-6,-`,5,4C747` 2/0 //> ADDRESS ! 4")/71.1(r-/C--d P /f /1./
CITYi6),r6e.)/G4 STAT ZIP (3 r� TEL TEL, P3�' J Y 0
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FAX CELL 7/2$ EMAI (',' /0 (, r(�- d '2i 7
ROUGHGAS INSPECTION NOTES 5 THIS PAGE FOR INSPECTOR USE ONLY __FINAL INSPECTION�{O
TEs
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
0/ FEE: $ PERMIT#
i/6�/ !l / c^ ? PLAN REVIEW NOTES