HomeMy WebLinkAboutBLDG-24-252 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY (.Dc_! ��I1ZMn0'71 MA DATE / !�/P(Z .Z� PERMIT I �3LD �5
JOBSITE.ADDRESS o�'t' ' �Opp 21' OWNER'SN.AME
TYPEOR OWNER ADDRESS C( C /C1c, hZJ� IES6 L k•2 /”.L FAX
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0.
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑
PLANS SUBMITTED:YES 0 NO❑
APPLIANCES 7 FLOORS-' sSM 1 2 3 4 5 6
BOILER 9 10 11 12 13 1-"
BOOSTER
CONVERSION BURNER
COOK STOVE X DIRECT VENT HEATER _
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS _
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSUI have a current liablli insurance policy or its substantial equivalent COVERAGENCE nt which meets the requirements of MGL.Ch.142 YES ❑ NO
ELI IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE SY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D OTHER TYPE INDEMNITY ❑ BOND D
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Masser 'netts General Laws rid that my signature on this permit application waives this requirement.
SI TURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER❑ AGENT ❑
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 corn
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. all Pertinent provision of the
PLUMBER-GASFITTER NAME iOr JMA.-f LICENSE#t:4'
SIGNATURE
MP 0 MGF❑ JPjkl, JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP❑it LLC❑#
COMPANY NAME '�-C(,J.4-vrq../ (l /v.-43 r�(J , ADDRESS /C-1 dcv 2c Ca..)
CITY w //A-
. /IQ U`jZ_ �--�/ STATE t, ZIP [��� TEL S-0 K.—
FAX /YlJ/� ,CELL Vb— Z I EMAIL .114,-.
CFirrca. N�T'
ES
1/j;i U G S SPE IO 0T PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
n - Yes No
THIS APPLICATION SERVES AS THE PERMIT• ❑ ❑
•
FEE: v PERMIT#
PL4J REYIE NO ES