HomeMy WebLinkAboutBLDG-25-229 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY: 4-127!4,110(_i -{t MA. DATE y -iv) Z5 PERMIT#C .DG-ZS Z: y
JOBSITE ADDRESS: 241 (4-y& ¶ PVI?C 13 J OWNER'S NAME:
GOWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAIC
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT PLANS SUBMITTED: YES❑ NO 0
APPLIANCES) FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER _
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
lr� INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
.J ROOF TOP UNIT
' TEST -
UNIT HEATER
14.1 UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES EZI NO 0
If you have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 1:71 OTHER TYPE INDEMNITY 0 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
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: D� El . -0 M t7I� LICENSE# ! 7 Z-T ALL G
COMPANY NAME: JTS ?L M-OW C ADDRESS: 7CT Ear5r OS-C-R. cLL 6--1,tr)
CITY: STATE: Ai 4- ZIP: CZ.(o55. FAX:
TEL: ?b57— .75 1(oci CELL: EMAIL: 0 Lc)M���i ��ll'cL 0'Afi-S_,.Ct"1
MASTER 5r, JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑#
1 APR 16 2025
BUILDING DEPARTMENT
By - - -----
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES