HomeMy WebLinkAboutBLDG-19--006380 �_ ` •_•. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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,�4 , CITY Yarl710u't in MA DATE 05/lO/Pi PERMIT#/°. b'-�9-� 44FO
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JOBSITE ADDRESS y -I h ui.o r i e-OO k (Z rA OWNER'S NAME 614-0,/ e A6.
GOWNER ADDRESS CI L-nu)," O09,r TEL 50o- 737I2G7 FAX
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IS
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CLEARLY NEW:❑ RENOVATION:'I REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES'1 FLOORS-4 BEM 6�c 1 2 3 4 5 6 7 8 9 10 11 12 13 11-4 BOILER
BOOSTER I
CONVERSION BURNER I
COOK STOVE X i
DIRECT VENT HEATER _ T
DRYER '
FIREPLACE —~
FRY DLATOR
FURNACE 1 -
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS i
MAKEUP AIR UNIT I
OVEN _ i
POOL HEATER •
i
ROOM/SPACE HEATER I '
ROOF TOP UNIT
TEST - .
UNIT HEATER
UNVENTED ROOM HEATER _y
WATER HEATER X ,+
OTHER 1 /.° -% i
INSURAWCE COVERAGE -
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES Z 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 ❑ 4 6 Q
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• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
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` Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
•`-' SIGNATURE OF OWNER OR AGENT 1
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 will be in compliance with all Pertinent provision of the
`` Massachusetts State Plumbing Code and Chapter.142 of the General Laws. jilijin_i /
PLUMBER-GASFITTER NAME LICENSE#12 5c SIGNATURE
MP ❑ MGF❑ JP [ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME AasOA Cel lV ADDRESS 26 C ►t B10Lin-1 `2,!1 I
CITY SCAn` tjar n1.,r ti�'h STATE ,/1/1 A ZIP 6 C L( TEL CS 0 Z�-[0—(../�GZ.
FAX CELL EMAIL nSc,M 't as COri'l
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FILIAL II<ISI'I
CTIG1 f NG`IEq
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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FEE: v PERMIT#
PLAN REVIEW NOTES
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