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HomeMy WebLinkAboutBLDG-20-002463 .- P>MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I It> 5 ; :I_,*H C€T A 4iii I MA DATE A')-6)c�-Jo/ 9 PERMIT#/'ram\a-4' 'GUa�/4 j� ��. JOBSITE ADDRESS a� i L C r' OWNERS NAMEZf 41nr,.) n l)(I.111e GOWNER ADDRESS ,5G 0- TEL 77tf 99/ 7Y,5y FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL®' PRINT CLEARLY NEW:❑ RENOVATION: kr REPLACEMENT: Q'"' PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS- BEM 1 3 4 © © ®® '13 t BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT DRYER FIREPLACE FRYOLATOR FURNACE 1 GENERATOR INFRARED HEATER ■ ■ � --I COCKSGRILLE LABOPJATORY - . . 1 I MAKEUP AIR UNIT OVEN _._.,.1 �7 s, i POOL HEATER i I ROOM I SPACE HEATER I — ROOF TOP UNIT iLDIIvErr — bn- ,�.— UNIT HEATER I UNVENTED ROOM HEATER I WATER HEATER v I -..J OTHERINSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES la NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ 1 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 i, 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 permit issued for this application will be in compile ith Pertinei provision of the .`IL Massachusetts State Plumbing Code and Chapter.142 of the General Laws. '1-1 IC) AL'-'-' PLUMBER-GASFITTER NAME f►''rte/- . /' Ocoriie LICENSE#%,5y/S^ SIGNATURE MP Vr MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY€�IAME�.O& .,) .•c.t 1 GG-S ADDRESS-70 Gi" e.i �' a I' pc weCITY /:r eS'ccc-fir. f k STATE M ct ZIP CV 6'4 a U TEL ?? .30-x/87-7 FAX CELL 5-0 3 7- 9177 EMAIL / d I 7 (0 i4'lS N, COjv _ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT# PLAN REVIEW NOTES