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HomeMy WebLinkAboutBLDG-19-001681 Cz ±L.2_______- )( "L-',.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �j "s CITY li(/, y�R MA DATE 2 -/2— /Z7 PERMIT�` �&/7-0©/a S? JOBSITE ADDRESS /y ' f i 2 ti R D iv 4/Z OWNER'S NAME,cL 4h/ # "0e-r I GOWNER ADDRESS // 1".2?47R/C/✓ n1 D (.4-)'d4 TEL //3.5'2f` % */ FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ems--- PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: . PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS—I BEM 1 ? 3 4 5 6 7 ° 9 10 11 12 '13 14 BOILER BOOSTER CONVERSION BURNER ■ DIRECT DRYER FIREPLACE FP.YULATOR _ r 1 INFRARED HEATER GRILLE i , MAKEUP AIR UNIT ! OVEN POOL HEATER • 1 ROOM/SPACE HEATER _ ROOF TOP UNIT _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER Ell I II I OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which m e requirements of IVIGL.Ch.142 YES mi NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE ECKIMG THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 Pertinent provision of the I Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME �j/dale, r-.Spq A 9 v., LICENSE# /N. y SIG ATURE MP I I MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#!: COMPANY NAME /Vi C yA1 L Se?/4 F -T ADDRESS 2 P p2 G,.J'>,Ot c f (..i r CITY kJ- ), 4P' STATE S l9 ZIP 02 G '7 TEL f'G e 52 z 0/GE I FAX d"C A---- CELLSki 922 0 1 e t EMAIL ®l/o vtr. ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY kI1�1AI INSPECTION NOIEq Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT{I PLAN REVIEW NOTES