HomeMy WebLinkAboutBLDG-25-376 RECEIVED
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GA TT
. CITY: It4RmnL MA. DATE of pFRMITit 06^� —3
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JOBSITEADDRESS: U`�KG Nilsen OWNER'S NAME: Brett%LF'RGv!�Cn7tvhENT
G ,OWNER ADDRESS: 41a 5 Pe`n6Et2-4 T60Q)24e.4{5-r- FAX:
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL f1
PRINT
CLEARLY NEW:❑ RENOVATION:53. REPLACEMENT:0 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
lit INFRARED HEATER
to LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
J ROOF TOP UNIT
fi TEST
Z) UNIT HEATER
UNVENTED 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 IN NO❑
If you have checked 1F,a,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this appication are hue and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit Issued for this applicator will be In complanc IW all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER/GASFITTER NAME: LICENSE#a67ry SIGNA URE
COMPANY NAME: G 'A' S2LFu. ADDRESS: ill SPean6Fk Lan'e
CITY: (/-1• Yfrr rrt• STATE: mA ZIP: Oa-6 73 FAX:
TEL:(SOP)114"143 CELL6:CP') " "'°ag` EMAIL: Selfevrt. & Yhhao.Cap. �nt
MASTER 0 JOURNEYMAN LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#��ry
c/rirli . , 1j V c--SS
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