HomeMy WebLinkAboutBLDG-18-000288 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
_ ( CITY C 0(.144,1 MA DATE n.-2/2/11PERMIT#A. G?I z-0t'C),Q
JOBSITE ADDRESS ict t. /t i AJ OWNER'S NAME bi Q,01 7i p pclyt e
GOWNER ADDRESS reo/t. L�f a_,� TEL iii.leats /S'51AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ J� EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: El PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR-4 Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE r
GENERATOR
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
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 ❑ 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 ❑
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 'h all Pe " n p(ovision of th
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Massachusetts State Plumbing Code and Chapter 142 of the General Laws. il1
PLUMBER/GASFITTER NAME: ` +"C L;)(14( hie° LICENSE# <
,'�� ,2 SIG AT RE
COMPANY NAME: ADDRESS: i, 706 /1
CITY: Wculee, STATE: /1/I > ZIP: Oar)/ FAX:
TEL: S-----Ac'( CELL: _%'))cii. cc -3'r EMAIL:
MASTER S JOURNEYMAN 111F LP INSTALLER S CORPORATION # PARTNERSHIP ilk# LLC #
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BELOW FOR OFFICE USE ONLY
FINAL INSPECTIONS SKETCHES FEE PROGRESS INSPECTIONS
/ &/ 5 NO.
`/ APPLICATION FOR PERMIT TO DO GASFITTING
7 01 iL7
NAME &TYPE OF BUILDING
LOCATION OF BUILDING
PLUMBER
PERMIT GRANTED
DATE 20
PLUMBING INSPECTOR