HomeMy WebLinkAboutBLDG-20-000530 MASSACHUSETT . NIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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eg CITY ,Xv
h4P, DATE �`�• 3 a 2 PEFtIv11T / o-W- S
JOBSITE ADDRESS G .7 6"Riy 4✓c La,,>-gr? OWNERS NAMEL4R,e' /O1 Pry e,,,-LCe
GOWNER ADDRESS 6 ?fie,a r 4,,-< <v. yq 2 TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
P)!t.1NT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑ 54 f'f rr r PLANS SUBMITTED: YES❑ NO❑ 1
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APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER i
BOOSTER - r 1
CONVERSION BURNER I
COOK STOVE /
DIRECT VENT HEATER ;
DRYER / —
FIREPLACE
FRYDLATOR
- -
FURNACE _
GENERATOR
GRILLE
INFRARED HEATER _ E C F I " E D ____1LABORATORY COCKS q
MAKEUP AIR UNIT _
OVEN _UL 130209 i
POOL HEATER •
ROOM I SPACE HEATER -- r R EN
BILL 61�Pi6"-E.��/� ,T M E idY -
ROOF TOP UNIT By: --
TEST r
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER
OTHER ,47A,A., p'P e-s 1
I i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalentwhich meets the requirements of MU.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO\'ERAC . CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ I
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
t 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
-� 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#t /7p7Y SIG TURE
MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑#F PARTNERSHIP❑# LLC❑#i:
COMPANY NAME "c iy, C Z7 S'pi?A 7 y r ADDRESS 2 3 f 2 Gj c7 ,4„-e•
CITY LC/, X47 . STATE /174 , ZIP Q Z 47 3 TEL f la - F2e - O/ga
FAX CELL$O, 52z G/fu4 EMAIL /1�',.-i-�-e
1Q# CICpla750 —
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL osPECTION NOTEs
Yes No
THIS APPLICATION SERVES AS THE PERMIT
7.4// i(//4 /
/! J ,4/ /p FEE: $ PERMIT 14
PLAN REVIEW NOTES