HomeMy WebLinkAboutBLDG-24-673 MASSACHUSEETTSn/ MA DATE �/ rjUNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
a CITY yQrMi? n
�
"r7C �JJJ. /�o PERMIT# 4Z3
Oay 2y_
JOBSITE ADDRESS 35 k20!/u/D/1 d /q// OWNERS NAME 2Fi1,P c /.3-5 1 /J(
GOWNER ADDRESS 3 ?'//u/OD I (Y TEL 7.9/-%a2'/-9331FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL L�J'PRINT
CLEARLY NEW:D RENOVATION:0 REPLACEMENT: PLANS SUBMITTED:YES 0 NO
APPLIANCES Z FLOORS—. BEM t 2 3 4 5 6 7s 9 to 11 12 is to
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM/SPACE HEATER
RROOF
TOP UNIT E E D
UNIT HEATER
UNVENTED ROOM HEATER Nny Q 1174 —
WATER HEATER
OTHER
�QP OU@ CQ,o DULv tin npRaRTE N-1-
De Ire(
e( ace
-Y c�� ----" I —
(v„ .,
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO® —
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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
Masi• chusetts General Laws and th m ignature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT❑
•IGNATURE OF OWt ER 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 knowled
and that all plumbing work and installations performed under the permit issued for this application will be in comp,tance with al P ne vision e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
it} J
GrAlat
PLUMBER-CASFITTER NAME LICENSE# (/6 5 g r SIGNATURE
MP 27 MGF❑ JP 0 JGF 0 LPGI 0 CORPORATION 0# PARTNERSHIP 0# / J LLC❑#
COMPANY��� NAME laO EQ/J (�4 S. /,/4 ADDRESS 35/ trk, 4100
CITY YGd/ OGt�/f!%// STATE. ZIP at?(p �7S TEL 78/-,L4?4—93'x?
FAX CELL 7G'C/- 93313 EMAIL 4We f/iS�d/ir. /9,e).6 ff,444)//'O#f-
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT [ 1 f J
FEE: $ PERMIT #
PLAN REVIEW NOTES