HomeMy WebLinkAboutBLDG-20-002357 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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1`F a`w CITY VIRVI4+0 Or 14 MA DATE /0• aZ rj-/' PERMITPERMIT#/� :'CO-Pdlfffi7
JOBSITE ADDRESS Cs (4—Nc_ cfa(c ti?'. OWNERS NAME Z i ?
OWNER ADDRESS ' f( TEL Vi-40134,,,.
77�� r,
TYPE OR ---�_
PRINT OCCUPANCY TYPE COMMERCIAL 0 �EDDUUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:LN PLANS
SUBMITTED:YES 0 NO❑
APPLIANCES 2 FLOORS-. BEN 1 2 3 a 5 6 0 9 10 11 12 BOILER 13 iF
BOOSTER -
CONVERSION BURNER
COOK STOVE -
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR - J
FURNACE
GENERATOR
GRILLE _ I
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN -
POOL HEATER I
ROOM I SPACE HEATER E -E -I V �[T t
ROOF TOP UNIT
TEST -_ __. .._.
UNIT HEATER • i • --CCT--25 CU I9 R S
IINVEIJTED ROOM HEATER
WATER HEATER c Nc o=FAR MrN
OTHER i___-1
INSURANCE
GE
I have a current liability insurance policy or its substantial equivalent whi h meets the requirements of MGL.Ch.142 YES NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND ❑
OWNERS 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 O Y: OWNER 0 A T 0
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru d accurate to the b
and that all plumbing work and Installations performed under the permit issued for this application will be in c i n with at Pertinent 'Ion of the
Li.) Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE 7`� SIG RE
MP❑ MGF❑ JP❑ JGF(J�LP//GII❑ CORPORATION 0 A PARTNERSHIP 0 0 LLC 0#
COMPANY NAME Aria r>mktr,44 t /AC;(4-- ell( ADDRESS c2 Fi+(7j 1r4AI 11.
CITY eL-VAA.l9J` lvr
STATE ZIP Oa7?60 TEL *X-- '.?"-17466A
FAX CELL EMAIL ADUA1UT,�r- el()6/4/, (.(i5fri,
Le6C Ca5�(o24 0_ -
ROElgTGSk H7G.f��_S I SPEC' 'EIS THIS PAGE FOR INSPECTOR SE ONLY FINAL INSPECTION NOTES
Yes N
THIS APPLICATION SERVES AS THE PERMIT n n
FEE: $ PERMIT #
PLAN REVIEW NOTES