HomeMy WebLinkAboutBLDG-25-92 - . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
.--fri J ' ` 2— C-2s- ro6 CITY Yd �10Ht or'r MA DATE PERMIT* Qc-DG-Z r l Z—
JOBSITE ADDRESS 4,2 9 /c c &ecfr y RR h OWNERS NAME 12Cirr- Ae,'S et)--2 4-4
OWNER ADDRESS TEL 7 7 C( 8 3 C 6-0 FAX
TYPE OR TYPE COMMERCIAL E DU
P��,�, OCCUPANCYCOMMERCIAL E '' � • NAL ❑ RESIDENTIAL❑�
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO E
APPLIANCES 1 FLOORS—+ Bsivi 1 2 3 1 5 6
7 8 9 10 'I'I 2 1� '13 14.
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER i
DRYER
FIREPLACE
1
FRY OLATOIR I
FURNACE
GENERATOR I
GRILLE
INFRARED HEATER I
LABORATORY COCKS •
MAKEUP AIR UNIT
i
OVEN
POOL HEATER
ROOM I SPACE HEATER '..� I a, a.
ROOF TOP UNIT
TEST ._ �_... .
UNIT HEATER [FEB-0-5t 1
UNVENTED ROOM HEATER L_ • _ _ .� I
WATER HEATER :UILDIN`=G u.- - ''I
OTHER v
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.'142 YES INO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 12— 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
Ma s c us.etts General Laws,and that my signature on this armit application waives this requirement.
CHECK ONE ONLY: OWNER—❑ AGENT El—
SI IATURE 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 co liance with all Pertinent provision of the
\--.. Massachusetts State Plumbing Code and Chapter.142 of the General Laws.
PLUMBER-GASFITTER NAME C L Ir . r so,,,,c.... LICENSE#t et, 33 O1( SIGNATURE
MP ❑ MGF❑ JP 0' JGF❑ LPG! ❑ CORPORATION❑t PARTNERSHIP❑# LLC❑#
d '�\ y
COMPANY NAME ce, C ADDRESS D I 5°'in k Tay S 1
1111 a
CITY T�/ hh 5' STATE'rn0. ZIP t)` a-6o I TEL (Ig 3 l'o l7 16 1
FAX CELL rr EMAIL 1 l �. m -rr �yv ,;.; C, b' ti \'. C,c�Il
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL'INSPECTION NOT'E,
Yes No
THIS APPLICATION SERVES AS THE PERMIT•
❑ ❑
FEE: $ PERMIT tI
PLAN REVIEW NOTES