HomeMy WebLinkAboutBLDG-19-007011 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
', �" CITY r m 0 jam/,, MA DATE 60Vil d— 1 � ob-
�. _ � (J 1 �1 `lll PERMIT# � I�-CX�
JOBSITE ADDRESS �o� 14Ye Ave--_,...-
OWNERS NAM 'E ae U 1()IC rvkk_
GOWNER ADDRESS 'S a. (->AV 4.,Q._ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ,--
PRINT
CLEARLY NEW:E RENOVATION: 0 REPLACEMENT: ❑/ PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS—F BSM 1 2 3 4 5 6 7 8 9 10 II 12 13 14
BOILER _
BOOSTER ____I
CONVERSION BURNER, _
COOK STOVE _
DIRECT VENT HEATER
DRYER
FIREPLACE o_._____y_ . .. .... .. .
FRYOLATOR
FURNACE
GENERATOR t
---I INFRARED
JUN 11 7019 I i
INFRAREDHEATER.
t- LABORATORY COCKS • aI
MAKEUP AIR UNIT !
OVEN i
POOL HEATER 1
_
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST _.- . . ... . .. +. - ---
UNIT HEATER _
LINVENTED ROOM HEATER 1
WATER HEATER
W OTHER
INSURANCE COVERAGE
- I have a current liability insurance policy or its substantial equivalent which meets the requirements of ItGL.Ch.142 YES [V/NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY 0 BOND ❑
3 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i
q Massachusetts General Laws,and that my signature on this permit application waives this requirement.
1
CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1
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
`k- and that all plumbing work and installations performed under the permit issued for this application will be in pliance wi a Pertinent provision of the
t Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE# 6 6 F6,,, SIGNATURE
MP 2/MGF 0 J ❑ JGF❑ LPGI CORPORATION❑# PARTNERSHIP❑# LLC 0# 1
COMPANY NAME 4- 1 OeiCt e \'1S,l`{ ADDRESS SS 1.15 €i i 1/e - W 7gri c '•/&
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CITY M ►1rs lus i"`J i STATE N17/� ZIP Oa 6lig TEL S68' P777 U6 I)
FAX CELL 5Ug 717 v% / 1 EMAIL '44— -
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5 � 0 � '+
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLI' 'INAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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N O'714—y ✓4 /
)(/ �- [- ' FEE: $ PERMIT
/ PLAN REVIEW NOTES
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