HomeMy WebLinkAboutBLDG-20-005451 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY: La-5! YC. ( en-a 0 l MA. DATE Li PERMIT# ! /)
JOBSITE ADDRESS: I ,)� SO 4tx OWNER'S NAME: Pk 1,6 1'S-,
GOWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ID%
PRINT � /
CLEARLY NEW:ElLK
RENOVATION:0 REPLACEMENT: ' PLANS SUBMI l 1ED: YES❑ NO❑
APPLIANCES FLOOR-, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE I
GENERATOR
GRILLE
VI INFRARED HEATER
LABORATORY COCK _
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
-J ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 2/NO 0
If you have checked Yam,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 9-/ 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.
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this applcation are true and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this applicalpnyll be In compliance with all Pertinent
provision of the Massachusetts State
.Plumbing Code and Chapter 142 of the General Laws. J c
PLUMBER/GASFITTER NAME: tL/awl C Ue�c LICENSE#3�`'/ SIGNATURE
COMPANY NAME:SIC eAA, ± ,{-k t%VI L ADDRESS: 1$ ``I 7,61(...4.1R. Ice-, ILL-(
CITY: (J Ce ( STATE: ( ZIP:Q.)(L7 3 I FAX:
TEL: 5O .- `_l,1`i O?L3) CELL_ EMAIL: 1;1 Y\ t�) Y (�'L,,.,,, Q.
MASTER❑ JOURNEYMAN❑ LP INSTALLER El CORPORATION❑# PARTNERSHIP❑# LLC❑#
ADDZe ss _ _
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT S
PLAN REVIEW NOTES