HomeMy WebLinkAboutBLDG-24-621 Sd,6O
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT T PERFORM GAS FITTING WORK
I
, CITY 1 41 � /'�. � O , / PERMIT# gLO G LW(e V MA DATE
GJOBSITE ADDRESS / 4p �✓c/ 51—_ OWNER'S NAME 4GWIJER ADDRESS 5'DY-TEL ,/ I. ,3 FAX__
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 5Z
PRINT
CLEARLY NEW:0 RENOVATION:i4 REPLACEMENT:vit PLANS SUBMITTED:YEkel NO 0 I
APPLIANCES 7 FLOORS—. BEM 1 2 3 1 5 6 7 8 9 10 11 12 13
BOILER tE
BOOSTER1111
CONVERSION BURNER
COOK STOVE > / _
DIRECT VENT HEAT RHO
DRYER
FIREPLACE
FRYOLATOR
FURNACE 1
GENERATOR -
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAK—EUP AIR UNIT
OVEN
POOL HEATER . - _
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST • •• • T_ a D 1
UNIT HEATER r I _
UNVENTED ROOM HEATER I _
WATER HEATER OCT 1'2OY4
OTHER
-
FUILDI\I'Uri ART
e -----—
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES IN NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE II4DEMNITY 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.
CHECK 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
yt Massachusetts State Plumbing Code ffandChapter 142 ofthegeneral Laws.
PLUMBER-GASFITTER NAMT '4I L O V- f t OL.e LICENSE# SIGNATURE
MP❑ MGF 0 JP® JGF❑ LPG'❑ CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NA E V -C. (JAL 4- ADDRESS 37 1 rGr /✓I) i1j e/l[,-(
CITY 111 1 l/1 11(5 STATE PM ZIP 0 Z(y cry-cry- TEL 7/O/L 7/?
FAX CELL EMAIL
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