HomeMy WebLinkAboutBLDG-24-161 3 .
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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- / 7 MA DATE 3 >I>y PERMIT#QLD_ Z=t b/_
JOBSITE ADDRESS 40 G(c.nlV.c..., p/- OWNERS NAME KPy.'i y�F+\zci ;,.r,
GOWNER ADDRESS CIO bfcin,dth't,,. i�r. TE(ro ta FM
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PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:i(] REPLACEMENT:0
PLANS SUBMITTED YES 0 NOfn
APPLIANCES-1 FLOORS-. 6SM 1 2 3 4 5 6 7 3 9 10 11 12 13 14
BOILER
BOOSTER -
CONVERSION BURNER,
COOK STOVE -
DIRECT VENT HEATERII
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN -
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST RFC . 1V+ � 7■
UNIT HEATER
U NVENTED ROOM HEATER — 'b ,ail 4 1
WATER HEATER
OTHER - - - _
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_ - -
INSURANCE
I have a current liability insurance policy or its substantial equivalent O nt whichCOVERAGE
the requirements of MGL Ch.142 YES ❑ NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGEHECKING THE APPROPRIATE BOX BELOW 0
BY C
LIABIUTY INSURANCE POLICY e 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 All ,and that my signature on this permit application waives this requirement.
� G^— CHECK ONE ONLY: OWNER❑ AGENT❑
J SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate t best of my knowledge
`- and that all plumbing work and Installations performed under the applicationp
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.ad for this will be in con li with at e'J nt� sion of the
PLUMBER-GASFITTER NAME LICENSE# '7I.11 GNATURE
MP L1 MGF 0 JP❑ JGF 0 LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC 0#
COMPANY NAME t4 lL K( ?' I4 ADDRESS b3 N 1 ✓ 136 S 4`7 Ic I
CITY )&1 t, ) STATE tMfI ZIP b L 6 34- TEL
FAX CELL S-i)3V(-Q'(16 EMAIL fa41ta/,.,_ CJ(o✓k-C-,f -ti
BQJJGH r*A G INSP CTE ION NO F ES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES
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