HomeMy WebLinkAboutBLDG-24-782 � ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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C'' tP�G CITY )4a4- ot4- MA DATE 0-a 3-a PERMIT f;BL vL-21 - "7 SZ
JOBSITE ADDRESS a02_5 `1 i- .28 OWNERS NAME 8C�/S iC)e Pso r'r
GOWNER ADDRESS TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLLEAP Y NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
APPLIANCES FLOORS-f BSM 1 2 3 4 5 6 7 9 10 11 12 13 f
BOILER
BOOSTER -
CONVERSION BURNER,
COOK STOVE i
DIRECT VENT HEATER ^J
i
DRYER '
i
FIREPLACE I
FRYOLATOR
FURNACE I
GENERATOR. -
GRILLE I
INFRARED HEATER — I
LABORATORY COCKS —1
MAKEUP AIR UNIT I
OVEN —,
POOL HEATER X
ROOM l SPACE HEATER __ y ;
ROOF TOP UNIT n - i� i
TEST . --- - - . ._ ... .._ .. s - - ,
UNIT HEATER C 2
UNVENTED ROOM HEATER
WATER HEATER
OTHER By
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU,Ch.142 YES Erin ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ 1
OWNER'S INSURANCE I ER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 M• <ar.h .efts Genes .a s,and that my Signature on this permit application waives this I'equirE:ment.
.
CHECK ONE ONLY: OWNER D AGENT
SI IATUR.E OF OWNER OR AGENT
"i-• I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd 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 Ii ce h all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter.142 of the General Laws. ��_--��
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PLUMBER-GASFITT R NAME LICENSE#91 3 3°1 J SIGNATURE
MP ❑ MGF 0 JP E JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME po;rt- P Re- ADDRESS t -s.t^f Tos !� S /�-
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CITY N y0`'„el%s STATEy•`k_ ZIP 6-AC0 ( TEL 77S( 83 ro 6V6(
FAX CELL EMAIL MC//c.4 1 bJ-er'26 ,j mail
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION{NGTE,
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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FEE: $ PERMIT lI
PLAN REVIEW NOTES