HomeMy WebLinkAboutBLDG-25-248 I�6-zc - z I
RECEIVED
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMI TO RFORN GAS FITTING ORK25
CITY:,4KrAN A MA. DATE: / 61J}I)
0/ / 4G DEPARTME T
JOBSITE ADDRESS: , &T �� OWNE 'S NA E: 5/ �(C.�/�[.
GOWNER ADDRESS: TEL: FAX:
TYPE OR 'OCCUPANCY COMMERCIAL D EDUCATIONAL❑ RESIDENTIAL Lys
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
LA INFRARED HEATER
jU LABORATORY COCK
MAKEUP AIR UNIT
4,3 4.) POOL
POOL HEATER
ROOM I SPACE HEATER
J ROOF TOP UNIT
fi TEST
Z UNIT HEATER
rL ERTED ROOM HEATER
WATER HEATER ',JJ
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent 'h meets the requirements of MGL.Ch.142 YES NO❑
If you have checked YILg please Indicate the type of coverage b 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❑
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 and that all plumbing work and installations performed under the permit Issued for this application will be omptance with all Pertinent
provision of the Massachusetts State Plumbing Code end Chapter 142�of_thee General Laws.
PLUMBER/GASFITTER AME' �,Z r rO,' �L GeIOEm5E1/ SIGNATURE
COMPANY NAME: L / I 1-17 AD�DRRESS:7i5q / .I m�(�j�[ f OAj 1
CITY: I'{r/-Y✓f STATE: AA* ZIP: u2- '7� FAX:
TEL: ' L: EMAIL: 'l(GC X fQ 4 v(05('it,t f1
MASTER OURNEYMAN INSTALLER❑ CORPORATION❑# PARTNERSHIP ID# LLC❑#
c h7I3 1C. ADIVZC-SS .
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: S PERMIT#
PLAN REVIEW NOTES