HomeMy WebLinkAboutBLDG-25-153 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ViCITY 'AILMOvTIt MA DATE 3 -I)-Z5 PERMIT# lkoG-2"r- irs
JOBSITE ADDRESS 21 G-iz- L "1 OWNER'S NAME VO\ FFco\ c
OWNER ADDRESS TEL FAX
TYPE OR �—
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL tZ
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
APPLIANCES"1 FLOORS-. BEM 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
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER R E C E L-®
ROOF TOP UNIT
TEST
UNIT HEATER id: - -
UNVENTED ROOM HEATER
WATER HEATER ) tfY_ -- }a.T
ME T
OTHER jc _
(�Vlt \4G OSE' 1-QS? - - -
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 BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 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❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information 1 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 permk issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Dame.) S IYl i f11 LICENSE# 1 Zo y SIGNATURE
MP 4 MGF❑ JP❑D JGF❑ LPGI ElCORPORATION❑# PARTNERSHIP El# LLC❑#
COMPANY NAME V)'5 `LU/-1yy N G. \-{VPC ADDRESS 79 E AST
CITY G ST-E1l\)"C LA,rc STATE .MA ZIP 6 2 C TEL Z S 7 ? O cr Gi cr
FAX CELL EMAIL 10TSP_UM\31ro( 4uR-C &-mPt-tL.ccyi-
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
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PLAN REVIEW NOTES