HomeMy WebLinkAboutBLDG-25-606 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY 4f�Mav71r I QA�
MA DATE (0(3 �� PERMIT#�7-ZS
JOBSITE ADDRESS 113 P l£A i e1 T S i -Sy OWNER'S NAME LOUI S tae,l„If ij6
OWNER ADDRESS TEL.SFr-39k-4670 FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 2
CLEARLY NEW:❑ RENOVATION:E REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO[
APPLIANCES 2 FLOORS-I 6SM 1 2 3 A 5 6 7 9 9 10 11 12 13 tt
BOILER
BOOSTER —�- �
CONVERSION BURNERI '�"`f ��1
COOK STOVE - s
DIRECT VENT HEATER85
DRYER Ii ,.
FIREPLACE �, - I
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 - I
INSURANCE COVERAGE ^�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO LJI
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts Gene 1 Laws,and that y signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER VAGENT 0
SIGNATURE OF OWNER OR AGENT
'<• I hereby certify that all of the details and information 1 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 all Pertinent provision of the
Massachusetts State PlumbingCode and Chapter 142 of the Li)
p1 General taws.
PLUMBER-GASFITTER NAME LICENSE#meLO17.r SIGNATURE
MP 1 MGF 0 JP❑ JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME 41,-77 S S r t/LS ADDRESS 60 y 37O
CITY yif2Wi o U 1I?one STATE,4t' ZIP OrZ 7S TEL yF 34.2 —Q 1.
FAX CELL EMAIL/714AU Y42_ rv1_E tr.Mi
1
--ION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT (l
FEE: $ PERMIT #
PLAN REVIEW NOTES