HomeMy WebLinkAboutBLDG-25-245 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
• CITY: 7pa1'��M1 � , C Hf
�_-; MA. DATE:4'
44 PERMIT# 13 0 G Z��— Z
JOBSITE ADDRESS:
G OWNER ADDRESS: TELI/11 I V AX:&� )ftiD
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 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
VI INFRARED HEATER
W LABORATORY COCK
OVEENUPAIR UNR _ RECEIVED
q POOL HEATER
ROOM/SPACE HEATER
J ROOF TOP UNIT - APR 2_ 201r
TEST
Z UNIT HEATER •JirLnINn nconpjMEN—
iyJ UN VENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 0 NO go
If you have checked 1F.4,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND❑
OWNS SU E IVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Mass u etts n ra and that my signature on this permit application waives this requiremenL
CHECK ONE ONLY: OWNER AGENT 0
SIG E 0 W R 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 end that all plumbing work and installations performed under the prank issued for this appllcat wlll be In co Hance II Pertinent
provision of the Massachusetts S Plumbing[Code end C ap er 142 o the General Laws. �j^1�Qp�1p4'�/W�_
PLUMBER/GASFITTE NAME: t 5 M!! LICENSE#j�-D 3a SI A
COMPA NAME: or) p4f'ff MA.
916 ^NIUISD'1I
CITtYy:„AAV ^^'-'1 j STATE:` IYT ZIP: 31$0 FAX::
TEL:/ /7•PO D OA IllCELL: EMAIL:I O M`10 Pe%f.6 6 9 icl.n IED'CD M
MASTER g JOURNEYMAN❑ LP INSTALLER❑ CORPORATION 0# PARTNERSHIP 0# LLC❑#
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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