HomeMy WebLinkAboutBLDG-19-05452 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
`"`:.' `�cQ 1 MA DATE 3 a.S (19 PERMITCITY �0 V' � bar IMF d't'1/� � � .�•�
,��s JOBSITE ADDRESS L1 -QC-'aacCI S 1 Ve .�\ OWNERS NAME_W1G1s t hl.X
GOWNER ADDRESS TEL-7 7 y-3S 3-'Tel If ZAY
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
P%tEN'T
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-1 FLOORS—F BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 1
BOILER
BOOSTER _ —.
CONVERSION BURNER
_
COOK STOVE
DIRECT VENT HEATER —�
DRYER
I
FIREPLACE '
FRYC)LATOR I
•
FURNACE
GENERATOR
I
GRILLE
INFRARED HEATER j
LABORATORY COCKS •
I
MAKEUP AIR UNIT
OVEN i
POOL HEATER
ROOM(SPACE HEATER
ROOF TOP UNIT
TEST ... . _ �� .!is,.. . ._ __ _.. .
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER (,,AS--- e_S i - _ —
i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of[>4GL.Ch.'I42 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 1
t Massachusetts General Laws,and that my signature on this permit application waives this requirement. I
I
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
'71, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur to to the best of my knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in compile e.with Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i
`!
PLUMBER-GASFITTER NA1A: 3' aQgJ LICENSE# SIGNATURE
MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# I
COMPANY NAME e0.26e_ {vrAl (%)I Ce> ADDRESS I bS ' .- k—A
CITY r.... (--e.wS4'e- c STATE V "`0,‘ ZIP cc; . 2( ;EL 7)'f`f7g `s-12 . j
FAX CELL-))q S77-s -L EMAII.,cl e, rreys-\ Jv"'\n \v_ru1cre_-
CD3 c �-o-- - GPq
TROUGH GAS INSPECTION NOTES THIS PAGE FORINSPECTOR R USE ONLY
IaII"IAL.€I<ISI�I;G�'IG1 I i�G`d'.�S
No
/1/4 54fi441- //-) 77W4--V THIS APPLICATION SERVES AS THE PERMIT Yes
V( r f`%?,(/1 /5413C gar FEE: $ PERMIT# •
PLAN REVIEW NOTES
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