HomeMy WebLinkAboutBLDG-24-515 50.a6
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-'` CITY Yr. r9 r PERMIT# .S1
'- " , Id�r f MA DATE Z F�c OG-2h-
JOBSITE ADDRESS /s Ra. (s..h y
?Iv Cc OWNERS NAME
OWNER ADDRESS TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL CI
CLEARLY NEW:D RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0
APPLIANCES 7 FLOORS-. OEM 1 2 3 A 5 6 8 9 10 11 _
BOILER y . 1' 13 iq
BOOSTER _�
CONVERSION BURNER, _
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE i
FRYDLATOR
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER
LABORATORY COCKS -
•MAKEUP AIR UNIT JI
OVEN
POOL HEATER -
ROOM/SPACE HEATER F �" E ' y t_ U AL ROOF TOP UNIT __
TEST
UNIT HEATER SEP 04 2014 '
UNVENTED ROOM HEATER -
WATER HEATER
OTHER BUI DINGDEPA iI MENT
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES IIO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Q/ 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.
CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
`',b, 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 com ante with all Pertinent provision of the
�' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#fi, SIGNATURE
MP 1:1,IMGF 0 JP 0 JGF 0 LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME t`t II I1 i -t' I`I- ADDRESS 70 ske "9e 9 o e� J
CITY VV`n4k�--« STATE 4 ZIP 02(oY9 TEL S'03 537 d24.2
FAX CELL Sam{ EMAIL'L4.I 0 16A1,117c► • CO.^-/
ROUGH GAS INSPECTION NOTES THIS PAGE FOB, INSPECTOR USE ONLY FINAL IN PECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT n 1
FEE: $ PERMIT ft
PLAN REVIEW NOTES