HomeMy WebLinkAboutBLDG-25-277 MASSACHUSETT NIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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?_ pp' CITY: 2M O MA. ATE: /) ( z5 PERMIT#3 �'6') -zr- -E-77
JOBSITE ADDRESS:of D C'u•C V•t+ 19°f I' OWNER'S NAME: 4/ V
G OWNER ADDRESS:c C i O i V+ /4i,, 4TEL:Ab `)& 71 WO/
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL Er
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED:YES❑ NO
APPLIANCES? FLOOR-. , Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR R F ' V C D i FURNACE _
GENERATOR t
GRILLE MAY 1 5 2025
VI INFRARED HEATER
LABORATORY COCK
k — — BUILO'i'. u=PARTMENI
"""...JJJ MAKEUPAIRUNR
' OVEN — --
,� POOL HEATER
ROOM/SPACE HEATER `
-J ROOF TOP UNIT
fi TEST
Z UNIT HEATER
IL 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 0 NO
B you have checked YES,please Indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY Ld OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mass usetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this app§cation are true and accurate to the est of my
Knowledge end that all plumbing work and installations performed under the permit issued for this application III be In compliance will I Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142of the General Laws./�
PLUMBER/GASFITTER NAME: V11;1/j S'L�LICENSE f lU J j SIGNAT
COMPANY NAME J/V V11 2/ f k-t-' 6 ADDRESS' f
CITY:I f v�if L� ` STATE: ZIP: j(51 f FAX:
TEL:, ' 4/7q CELL: EMAIL G Pt-imp iPoe-- gr 0)0, d
MASTER❑ JOURNEYMAN(J LP INSTALLER 0 CORPORATION 0# PARTNERSHIP❑/# v LLC 0#
E m e/4. ALOwess:£- pull.,f)(t C iCi29 1,r\iej---
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES