HomeMy WebLinkAboutBLDG-25-421 RECE1ol
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"'gRIACHUSETT8 UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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_/ CITY: at' DAT' PERJMIT# J
JOBSITEADDRESS: l /r. OWNERS NAME 2/1/P/ x`.44148
GOWNER ADDRESS:3 D TEL: 7A/4Q /? 3/
TYPE OR OCCUPANCY E COMMERCIAL El 'EDUCATIONAL 0 RESIDENTIAL L�
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:❑ PLANS SUBMFITED:YES❑ NO❑
APPLIANCES) FLOOR-. Bemt 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 1
FRYOLATOR
FURNACE
GENERATOR _
GRILLE
LA INFRARED HEATER
W LABORATORY COCK
MAKEUP AIR UNIT
St OVEN
POOL HEATER
ROOM I SPACE HEATER
J ROOF TOP UNIT
Q TEST
.Z UNIT HEATER
144 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❑NO
If you have checked YIF,§,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIV R:I am aware the lic see s ve the insurance coverage required by Chapter 142 of the
Massact rsetts General my wiz o r ft application waives this requirement
�%C/�i� ��/ r/l-, CHECK ONE ONLY: OWNER AGENT 0
SIGATURE OF OWNER)) NT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the be of my
Knowledge and that all plumbing work and installations performed under the permit Issued for this application be Inca
provision of the Massachusetts State Plumbing Code and Chapter 142 thq Genera c--
PLUMBERJGASFITTER N4ME r /+J (�/ LIC SE# / TUJJtE//I
COMPANY NAME: ✓Gs(' 1 `C- �. O4Yl ADDRESS: /-7It?D!�t// or/ Jf•
CITY: STATE:PA• ZIP: /J�C ! 1 SAX —�--
TEL: CELLEMAIL CJon %r Ah /9,,O p pl o ,tO;14
MASTER JOURNEYMAN 0 LP INSTALLER❑ CORPORATION 0# PARTNERSHIP 0# LLC 0#
E lr1011 ADU2eSS:. da4 0 ki'l o/,,y1 /990(
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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 I
PLAN REVIEW NOTES