HomeMy WebLinkAboutBLDG-20-002354 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`= :Iror CITY `19-1 Y"RturN MA DATE //) r ac - /g PERMIT#/06.20727gloW
JOBSITE ADDRESS a \-tivk-ki ( WNER'S NAME PAU C- LtJ(7�CI �c
`� t k TEL C. L ?�OWNER ADDRESSc
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Tr
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CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: (1 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 BEM 1 2 3 1 5 6 7 ° 9 _ 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER ---
DRYER
FIREPLACE
FRYOLATOR
FURNACE _
GENERATOR
GRILLE
INFRARED HEATER —7
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN • —.1
POOL HEATER
ROOM 1 SPACE HEATER
ROOF TOP UNIT
TEST -.. .-
.
UNIT HEATER _
UNVENTED ROOM HEATER •
WATER HEATER I 1
OTHER l
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE 1E 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 1
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE'NLY: OWNER AGENT ❑
`' SIGNATURE OF OWNER OR AGENT
rl-. I hereby certify that all of the details and information I have submitted or entered regarding this application are land and accurate to th st of my knowledge
`k- and that all plumbing work and installations performed under the permit issued for this application will be in ci'Finance.with all-Perti provision of the
Massachusetts State Plumbing Code and Chapter.142 of the General Laws.Li 1
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PLUMBER-GASFITTER NAME LICENSE#.f S TU ,E
MP ❑ MGF❑ JP ❑ JGF(ILl LPG,'❑ CORPORATION❑# PARTNERSHIP❑# LLC❑It
COMPANY NAME APO*50 / 4 C ADDRESS F-A( f4A1 i?C7.
CITY a,y}1ii( lJT 1� STATE f/�A, ZIP 03-3 6 TEL
TEL '7 _ j P_ 1'J�U et
FAX CELL EMAIL/�`—' 1`'C,4-('J� Q-flf{{_4 6,..p f(ze, (ovi
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NO`I'Ec4
Yez No
THIS APPLICATION SERVES AS THE PERMIT ❑ []
FEE: $ PERMIT/I
PLAN REVIEW NOTES