HomeMy WebLinkAboutBLDG-24-662 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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F �0 CITY '><a✓w10 en 4. MA DATE /O / 2 PERMIT#BI-1"D4-2�'(-CO47--
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G JOBSITE ADDRESS S-� R G H O a(vi aci OWNER'S NAME e i•.4(4 Yyl jlz y kC,
OWNER ADDRESS Syv»c TEL y7F1-ZJo-2g[?h r
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Ift----
PRINT
CLEARLY NEW:[f RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO
APPLIANCES 1 FLOORS BEl1 1 2 3 4 5 6 7 J 8 9 10 11 12 13 14 1
BOILER
BOOSTER --1
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS V
MAKEUP AIR UNIT R C v
OVEN _;
POOL HEATER { V 111.:1 3 1 e:r cF
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST DUtkrnNG DEPARIrmE
UNIT HEATER
UNVENTED ROOM HEATER I —
WATER HEATER I —
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY lE"-- 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
3CHECK ONE ONLY: OWNER 0 AGENT 0
. SIGNATURE OF 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 Pertinent provision of the
-t' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBE,GASFITTERNAME DAn PIelal"501" LICENSE# J zY L b SIGNATURE
MP MGF 0 JP 0 JGF` 0/LPGI 0 CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME `�4vi /rI•Gi i ui,i (44/ / �/�� 5-4
ADDRESS // T�Ji61‹su�4 t"r65 Sf pt
CITY l Oar')Sr<tl,!>` STATE AZ ZIP 7 TEL �I Z2/-( 155—
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CELL EMAIL D4q b.yrg !L ¢ V4400, /L, -'e
ROUGH GAS INSFECTIQN NOTES, THIS PAGE FOR iN,SPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT l 1 1 1
FEE: $ PERMIT
PLAN REVIEW NOTES