HomeMy WebLinkAboutBLDG-25-10 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY t5-yGw'Ynou'-1h1- MA, DATE ICAC 3, a PERMIT ��— --- lcj
JOBSITE ADDRESS 3 Po s✓1 S t f'f/c, A - OWNER'S NAME Pa / Ron+1 e y
OWNER.ADDRESS 5 a m t • TEL 7 4-/ - 31r3e1FAx
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ( PLANS SUBMITTED: YES NO❑
APPLIANCES 4 FLOORS-4 BEM 1 2 3 4 5 6 7 8
9 10 'I'I 2 1� '13 1!
BOILER
BOOSTER j
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER —�
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER
LABORATORY COCKS €
MAKEUP AIR UNITR OVEN C I — I
POOL HEATER •
ROOM/SPACE HEATER ,AN i 3
ROOF TOP UNIT
TEST _ .
_. __... : • ., I. -- a n. I I
UNIT HEATER By:
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of 111IGL.Ch.142 YES ® 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 ❑
• 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 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 •th all P rt€neat provision of the
Massachusetts State Plumbing Code and Chapter•142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# .3.7 S`3 SIGNATURE
MP ❑ MGF❑ JP54 JGF❑ LPG' ❑ CORPORATION❑ ##i PARTNERSHIP # LLC❑
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COMPANY NAME �l u cv I<'a nc rc.c -/n 9 ADDRESS 3 9 Mao c ►'-Ys o y iZC
CITY 5. y0(WI STATE rnc ZIP 0 a_6 6 ce TEL
FAX CELL SOB 6$S S6SG EMAIL J f�Q ► .e I-is" va(10 7 coon
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: r PERMIT#
•
FLAN REVIEW NOTES