HomeMy WebLinkAboutBLDG-24-753 S-O.0
.0. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
‘,,,,,,,..,,,zit, CITY vI rm0E41- MA DATETG °I -Zq PERMIT#DLO 6,-2`r-7s3
JOBSITE ADDRESS IC\ W s.honvel S OWNER'S NAME --jr Oc L 00 k
OWNER ADDRESS 5 Pone- TEL —FAX,_
TYPE OF. OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL L�J�/
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0
APPLIANCES 7 FLOORS-• ESSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER IR FL F J V _
DRYER
FIREPLACE
FRYOLATORDEC et 2024 -
FURNACE
GENERATOR ggU I L D'NU L h PA H 1 M t ry i
GRILLE �Y INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT R-E C-E 1,VF 0
OVEN
POOL HEATER •
ROOM!SPACE HEATER nOr
ROOF TOP UNIT —
TEST ..... ...._ _... - • r i r11N6 DEP4RTM ENT
UNIT HEATER --Y _j -
UNVENTED ROOM HEATER
WATER HEATER
OTHER
6p.,. ►.,ems-%et-- P,Fe l -
INSURANCE COVERAGE
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE HECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L 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❑ AGENT❑
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 crenpli. -with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#)0756, SIGN RE
MP K1 MGF 0 �JPP 0 JGF 0 LPGI❑ CORPORATION❑# PARTNERSHIP 0# LLC 0*
COMPANY NAME T� AL45 Le a1u�`j ADDRESS I /=Jnn pool /21-9
CITY �Q nri i c I STATE/ZS4 ZIP 2 660 TEL col-3/y_ a 904
FAX CELL rf;3ly!..0V 0
F EMAIL Pi nlas/e/ ba e 4-ftka. 1-6m
---- ---------- -------- - ---------- ---------- _
ROUGH GAS INSFECTION I E5 THIS FAGS FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes N
THIS APPLICATION SERVES AS THE PERMIT I J
FEE: $ PERMIT tt
PLAN REVIEW NOTES