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HomeMy WebLinkAboutBLDG-17-004096 :if-,„,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK :4 ,J CITY/Grrj^t1dc,7% fah,', DATE 3 "-/G / 2 PERMIT 4 i7 O - Via-- y�w JOBSITEADDRESS/.S—CMG/74s7t., 4-/�///OWNER'S NAME DC,�'/ e z �`^77 GOWNER ADDRESS l.S CQ/ , '2 S7` V2/7 TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL IliEDUCATIONAL ❑ RESIDENTIAL LS" ' CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ APPLIANCES�t FLOORS-- BSIJM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER _ CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER I_ DRYER ' i FIREPLACE FRYOLATOR I FURNACE a I ,Iri f GENERATOR I GRILLE i INFRARED HEATER `+;46 'v 1 3 LABORATORY COCKS g MAKEUP AIR UNIT OVEN POOL HEATER 1 ROOM/SPACE HEATER I ROOF TOP UNIT - TEST - UNIT HEATER UNVENTED ROOM HEATER I WATER HEATER 1 I OTHER I _ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU.Ch.142 YES i0 ❑ 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 aw e that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts G eral Law. rid ti - ' c re on this permit application waives this requirement. I - eVCHECK ONE ONLY: OWNER AGENT ❑ 1`}// SIGNATURE ' 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 Pertin provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.iLui l ,,.....„—.7--.),..--1-- PLUMBER-GASFITTER NAME Sarz)c•� 1 oryrsS LICENSE 4 j-,3i 3 SIGNATURE MP ❑ IMF❑ �JP,© JGF❑ LPG! ❑ CORPORATION+' ❑# PARTNERSHIP❑#t LLC❑#t COMPANY NAME ! ►lIfe P M, 6 Lv r e 6 J/"I M ADDRESS (39( it/iik ) 5f" CITY 10=14 8,1.,0,51m4 le. STATE /a x ZIP 0,2 fv 6 $ TEL FAX CELL 5( Gr3 36Li /6 EMAIL rLvipiJ 6.) 7//`�4„..,.r/CC.4c ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ [] FEE: $ PERMIT ft PLAN REVIEW NOTES 7