HomeMy WebLinkAboutBLDG-25-369 MASSACHUSETTS UNIFORMN APPLICATION FOR A
PERMIT TO PE 70 GAS FITTING WORK/
CITY: �tr l [�J/I/M/�`'OAT6!t �'l / ERMIT# 34-6C-- J 3(„y
JOBSITE ADDRESS: 6 ' 7- Z8 OWNER'S NAM:
G OWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
APPLIANCES) 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
trj INFRARED HEATER
W LABORATORY COCK
kMAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
J ROOF TOP UNIT
TEST
Z UNIT HEATER
14.4 UNVENTED ROOM HEATER
WAEATER
7 HEATER
N�rt1Z r3�i z 1Al'SPP;c__7 Sot L-&-12_ ,JO
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO❑
If you have checked al please Indicate the type of coverage checking the appropriate box below.
LIABILITY INSURANCE POLICY 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT❑
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 an accurate to the best of my
Knowledge end that all plumbing work and installations performed under the permit Issued for this application will be comptance with all Pertinent
provision of the Massachusetts State Plumbing Code andChapter 142 of the Generalp� Laws. /�
PLUMBER/GASFITTERN ME: AJ �(/'YM�1�\�C-0 BIC�F ' ! 53 SIGNATURE
COMPAN�yN/p-M/,LE: ADDRESS:26J ��l 2 -1 ��
CITY
jj����C++f22t 0��U T� STATE:(N/� ZIP:Q7 J FAX:
TELLf3.JI� -1- ELL: EMAIL:641 C F66POUCOS
MASTER❑ JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑# PARTNERS LLC❑#
E ADitizess R E C y%E D
JUL 0 71015 I
BYUILDING DEPARTME"J'f
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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