HomeMy WebLinkAboutBLDG-19-002967 `' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
J( " �/, -P4- MA DATE !j-d PERMIT#
P: sN CIT( :. Cl� a�wG�.
JOBSITE ADDRESS'J411 wIf /� OWNER'S NA / -i A,-ARL.cy
GOWNER ADDRESS 2// a (t'1 TELS2Y3 L3 FAX
TYPE OCCUPANT TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Nit
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO
APPLIANCES T FLOORS 2 2
BJJ� 13 1 5 6 7 9 10 I'I t.. '13 I 14
BOILER
BOOSTER -j
CONVERSION BURNER ■ !
COOK STOVE
DIRECT VENT HEATER
I
DRYER
FIREPLACE
FRYCiLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER ❑ ❑ _
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT _ / i d
TEST . . ... .. II r "r
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER i
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 TI-IE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
I
OWNER'S IN. URANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massaach ' tts General Laws,andthat y signature on this permit application waives this requirement.
i
CHECK ONE ONLY: OWNER AGENT ❑
. IGNATURE OF NER OR AGENT J
•i, I hereby c rtify that all of the detail nd information I have submitted or entered regarding this application are true and accurat to the best o; my knowledge
``?- and that a I plumbing work and installations performed under the permit issued for this application will be in co p' ncp�with al ' cot pro )sio f the
.
Massachusetts State Plumbing Code and Chapter'142 of the General Laws.
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PLUMBER-GASFITTER NAME Yilabt.,24l �nl(6 LICENSE# 33 / SIG TURF
MP ❑ MGF❑ JP ❑ JGF❑ LPG! ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑#
COMPANY NAME ADDRESS /2,, LA-1 Pout vi L/1//
CITY Ycrrees Cj v1 1 t,po r STATE N`, It ZIP c2).6-2 5 TEL 7/y!.,-1 -Id;97 1
FAX CELL )) rV5-61)-J 6'I EMAIL r►1 iChaie) 33 6 t,,..1,ut9. C-D/^'1
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY __FINAL INSPECTION 1'1OIEti
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
7 /I i!Z;' L/ FEE: $ PERMIT ft
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