HomeMy WebLinkAboutBLDG-20-004638 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMET TO PERFORM GAS FITTING WORK
_6 CITYy1*JMosA4/\ MA DATE a la( ra v PERMIT
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JOBsI E ADDRESS a-c- (,),PAL___ l(- j__OOWNER'S NAME
GOWNER ADDRESS (9?f 1Ift k S4 € AQ , tiT�l 5-Ur 237 /2 o
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL -
CLEARLY NEW: rl I RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO k*-'
APPLIANCES FLOORS
-+ 6'CKA 1 2 3 4 5 6 7 8 9 10 'I'I 12 13 �
BOILER .Jl`
BOOSTER
—__H
CONVERSION BURNER
COOK STOVE A. I 1- — I
DIRECT VENT HEATER 1
DRYER _: I
FIREPLACE a- 1
FRYOLATOR I
FURNACE
GENERATOR 1, 1
GRILLE i
INFRARED HEATER - I
LABORATORY COCKS - WED ' j
MAKEUP AIR UNIT - 1 I
OVEN �� � � i
POOL HEATER
ROOM I SPACE HEATER _ '
ROOF TOP UNIT .war-i" ' ";'.
TEST -.. r .-
UNIT HEATER
UNVENTED ROOM HEATER •
WATER HEATER
OTHER
_
INSURANCE COVERAGE �-,�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES °ID ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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.
i
•,- CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT j
-!_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 comp'. nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME41V0-6:41) t/...SI r—I LICENSE#26 y SIG URE
MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME '► �n� �,'LC ADDRESS 706 /vfivfr1441L 04
CITY STATE ZIP 2 TEL c-o c A Y
FAX CELL EMAIL 5'-i-eij 14)04,10-0-- 6Pyil4, I:: co r`'k
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY IalNAL INSPECTION NOT„s
'(es Nu ,1/J -L CA-S i 5 �oo
(2775
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
749 6 FEE: $ PERMIT#
PLAN REVIEW NOTES
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