HomeMy WebLinkAboutBLDG-23-9697 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY L /. l 4 /'/y)4 r]al MA DATE Z
PERMIT# g L�(�- -�f6%'7
JOB SSITEADDRESS 7 ra�U� ��f_/ t_ct; D`I fL tl/Y4✓Z
OWNER'S NAMEG GWNER ADDRESS 2O /C I/t y k ctrp (A)'e f L-6/y O 7
TYPE OR ! 5 �i5 FAX_______________
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
CLEARLY ❑ RERESIDENTIAL
NEW: RENOVATION:❑ REPLACEMENT:❑
PLANS SUBMITTED:YES GI.,NO❑
APPLIANCES 7 FLOORS-. BEM 1 2 3 4 5 F 1
BOILER 9 to 11 12 13 ,
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT'VENT HEATER /
DRYER
FIREPLACE
FRYOLATOR
FURNACE
/
GENERATOR I
GRILLE
INFRARED HEATER _
LABORATORY COCKS —j
MAKEUP AIR UNIT -
OVEN
POOL HEATER _ _ _ L_i
ROOM I SPACE HEATER
ROOF TOP UNIT -
TEST
UNIT HEATER _
INVENTED ROOM HEATER J4[ _
WATER HEATER _ --_ -
OTHER
NOV 22 23 1 I
+ I
❑Ull Dino_r, u,a rinr�,
INSUANCE
GE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 11 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY j OTHER TYPE INDEMNITY 0 BOND ❑
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 I: 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 compliance with alll_f ertinent provision of the
�) Massachusetts State Plumbing Code and/Chapter 142 of the General Laws. 9 (l
PLUMBER-GASFITTER NAME I't i G,L4.6'L PM'(--)3 r t LICENSE#/I 5 GNATURE
MP 0 MGF 0 JP E . JGF 0 LPGI CORPORATION❑# PARTN-RSHIPI❑#/ LLC❑#";�
CSMPAN IJAME 1 /�f t -�- ADDRESS - 7 r 4 n l/`.(1 v\ N"1 .1 t/t
CITY T 1 litlrN. /\`I. S STATE Mr- ZIP () i('6 / TEL -7 7 Y 7 7 i Z
FAX CELL EMAIL I _dry‘ i r X �(-1
OUGgI GAS Ii*fSPEC'T'IGP� ‘(OTES
THIS PAGE FOR INSPECTOR USE ONLY' FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
• FEE: v PERMIT#
• PLAN REVIEW NOTES