HomeMy WebLinkAboutBLDG-20-000034 `' M ASSAC:HUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
c4iWi CITY SUv 16 iaA MA DATE (7— I_ 1I I PERMIT# /f^06/40-494° y
JOBSITE ADDRESS S L kJt cv1E Alren OWNERS NAME 'G(AQyj4 S1 j C( „ -
GGWNER ADDRESS 57-- VI:0e aye' TEL TN —R 16.- i 3 FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ii
PRINT
CLEARLY NEW:❑ RENOVATION: rJ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO
APPLIANCES T FLOORS-4 BEM 1 2 3 4 5 6 7 8 9 10 11 12 13 1!
BOILER --1
BOOSTER _
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYGLATOR
FURNACE
GENERATOR
GRILLE _ _
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _
OVEN 1i1
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST '
UNIT HEATER
UNVENTED ROOM HEATER 1
WATER HEATER
OTHER I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of tfGL.Ch.142 YES 040 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE 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 .
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 corn nce with all Pertinent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
L! (fu
PLUMBER-GASFITTER NAME fAY`VScY1 Ce-1'1-1 LICENSE# rp-( 3- SIGNATURE
MP ❑ MGF❑ JPrJGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑# Lc El
NAME �6 Ctl it, . ADDRESS 7 C Ckekti A lcslitna- RD l
CITY 2,r)t (14(r 't STATE Al/q- ZIP 02ZCo(„( TEL
FAX CELL EMAIL J I'Ls Ar\6e (;ti e Yu flow- C-'orn
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes N
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
p I
// � PERMIT tE
L G,(r /�A9/ PLAN REVIEW NOTES
•
•