HomeMy WebLinkAboutBLDG-24-607 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CIT( �I�M���'1 MA DATE /Ova • a ci PERMIT#13L"-V"-
JOBSITE ADDRESS lB 9 req Pi A e. Rom) OWNERS NAME m oreF1v
OWNER ADDRESS I�4 yr►B oPt ne. /4" TE( Of1 1/-4)6 a FAX
TYPE OROCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: yVt REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS-h BSM 1 2 3 l 5 6 7 8 9 10 111 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE --- ' _-
DIRECT VENT HEATER
DRYER
i I
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR •
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT _
TEST • • `
UNIT HEATER
UNVENTED ROOM HEATER i l
WATER HEATERHet
T r 2924
OTHER
3D!LDING pARi ry ENT
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of 1111GL.Ch.142 YES ] NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q 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 with all Pertinei rovision of the
• Massachusetts State Plumbing Code and Chapter.I42 of the General Laws.
PLUMBER-GASFITTER NAMEt'sREEso .l kc LICENSE#all/V SIGNA URE
MP ❑ MGF❑ JP gl JGF❑ LPGI ❑ CORPORATION❑tF PARTNERSHIP❑# LLC❑#
COMPANY NAME 6R€6OLySGtit P C-1061n Jy Gt. ADDRESS qt RtAa billG
CITY 6')' P111104f-fel STATE 111A ZIP D�vZ 3
TEL Ltggrrg. [Ct3Cj
FAX CEL 5-O )%ng - 4 EMAIL gel Fe Zee 4 e y ktv. co"
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes N
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# •
PLAN REVIEW NOTES