HomeMy WebLinkAboutBLDG-25-323 RECEIVED
rJUtk15/.02- 025
_g:J. MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO
PERFORM GAS Fk ii1481 ORKA21 MENT
f CITY: ✓Tr MA. DATE:_tr., '6. /IZ5.--PERMIT#3Lb P 24'3
JOBSITE ADDRESS: D f2'S NAME: kilTx"
GOWNER ADDRESS: 64-41. 1' TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL lEr
PRINT
CLEARLY i NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO❑
APPLIANCES1 FLOOR Burnt 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
FURNACE
GENERATOR
GRILLE
Vt INFRARED HEATER
W LABORATORY COCK
kMAKEUP AIR UNIT
4J OVEN
POOL HEATER
ROOM ISPACE HEATER
.l ROOF TOP UNIT
' TEST '
Z UNIT HEATER
iki UNVENTED ROOM HEATER
WAT.HATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES N0'0
If you have checked YES.please Indicate the type of coverage ecking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts 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 application are true and accurate to the best of my
Knowledge end that all plumbing work and installations performed under the permit issued for Ns application will be In co !lance with all Pertinent
provision of the Massachusetts Stat Plotting Code and
d Chapter 1422,of/the General yLaws.
PLUMBERIGASFITTER E:�GU 0/17 ML I✓��SEMSt'#�b7'gl� 7 f9.//,S�I�GNAT�UR/E� /��
COMPANY NAME` ��T ! D tf ADDRESS: 2/�� r5� ,/11 IK"At V /''
CITY: j Q��14M STATE: AAA ZIP:O 2 73 FAX:
TEL:505C 90 .4`T igL: EMAIL:
MASTER JOURNEYMAN INSTALLER❑ CORPORATION❑# PARTNERSHIP)❑ LLC 0
C irk/3iC. ADDeZe 5S:.1(f i1 An. nT(ems �f,/ I {�/il i r' e.GF"
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT#
PLAN REVIEW NOTES