HomeMy WebLinkAboutBLDG-17-002159 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
S-N40 e.1' CITY Yo! ove,(54 MA DATE kV?V/6 PERMIT#047--17-evollr?
JOBSITE ADDRESS 74PJtL , k OWNER'S NAME kusr-P p 'ROM k
GOWNER ADDRESS 20 rkh 1--el c,Cr" TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL r] EDUCATIONAL D RESIDENTIAL
PRINT
CLEARLY NEW:1=1 RENOVATION: Z._ REPLACEMENT: El PLANS SUBMITTED: YES NO El
APPLIANCES 1 FLOORS—+ BSM 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
INFRARED-HEATER
LABORAT• COCKS
MAKMINIUP. UNIT
POOL A,ER
BOOM/SFSCE HEATER
ROOF TOPI JNIT
TEST
! 1;3 UNIT HEAITER
UNVENFEJ)ROOM HEATER
WATERI-S\TER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND LI
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
ft.L) 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 wilt be in compr ce • all inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE# SIG RE
MP LI MGF 0 JP JGF LI LPGI 0 CORPORATION 0 It PARTNERSHIP LI# LLC LI#
COMPANY NAME -Jil-Dovoty ettAyib,), . ADDRESS 10 scoi- r 6/bat1 44'
CITY S.-vef 04547 , 414- STATE MA- ZIP "C:r2Zteei TEL <7-e—WI-52-.5-7
FAX CELL e---2.2-1f--5-2C1 EMAIL 3t-dotA/Pt-e7 7lumbr-4.2
Z--0e3/4
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