HomeMy WebLinkAboutBLDG-20-004336 1-,.... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CfTV t__fLy_/ MA DATE PERMIT#/ 46-0B�,116.
JOBSITE ADDRESS.4 7 16' OWNERS NAME Atoy�p �.,e-
G OWNER ADDRESS TES- ✓—FAX _
TYPE OR OCCUPANCY l E COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL Lys PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO Q/
APPLIANCES 7 FLOORS-. BEM 1 2 3 4 5 6 7 0 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER —
COOK STOVE
DIRECT VENT HEATER
DRYER —
FIREPLACE i
FRYOLATOR
FURNACE —J
GENERATOR
GRILLE
INFRARED HEATER
_1
LABORATORY COCKS
OVEN
UP AIR UNIT \-!(•:1_, C E%V E V
—,
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
— 6 2�1�
...
TEST
... ." . -.. ... ..... ....- --... -tT i •' PARTMEIlT _ .. _._
UNIT HEATER our vt
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ErNII❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0
°t.�, I hereby certify that all of the dalls and information I have submttted or entered regarding this application are true and accurate to the best of my Imowledge
and that all plumbing work and installations performed undar the permit issued for this application will be in compliance with all Pertinent provision
Massachusetts State Plumbing Code and Chapter�� J1142 of the General Laws.
PLUMBER-GGASFITTERNAMW/`/G(!>-6 LIC/ENSE#7/J'7 SIGNATURE
MP EV GF❑ JP 0 JGF 0 LPGI 0J/ CORPORATION g#' PARTNERSHIP 0# LLC 0#
COMPANY NAME v' ' �lttivy6 ADDRESS^ 0 �C /�11�
CITY Gt/• .694/I� STATE _ ZIP G PI
FAX,� �'j g�// n�� TEL �a- �Y316
CELL--LP7 3e_ j EMAIL/?�� 7 /e ' j t c_6,..4...„
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I1G SAS I �P' 3� �1�� If � S THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION COTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT (l
PEE: PERMIT tt
PLAN REVIEW NOTES