HomeMy WebLinkAboutBLDG-25-97 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ra. CITY `kp/i[ 7- MA DATE a- [-a6 PERMIT ft 66DG-Z -- 9 7
JOBSITE ADDRESS'6 to-r/r5ft OWNER'S N.4ME(i. aj Q a iv
G OM ER �L7 i'.21). TEL 1 Yg/-$174AX_--
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL L�
PRINT /CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:I� PLANS SUBMITTED:YES 0 NO 0
APPLIANCES 7 FLOORS+ iSM 1 2 a 5 6 8 9 10 11 12 I
BOILER 13 to
BOOSTER
CONVERSION BURNER
COOK STOVE •
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYDLATOR 1
FURNACE "` -
GENERATOR -
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT -� I
OVEN R-C ICHF E1 B , i
1
POOL HEATER — "
ROOM I SPACE HEATER -
[FE13 0_7 7n94
ROOF TOP UNIT
TEST -
UNIT HEATER OUILDfrt�O[I3�hTMCNT
UNVENTED ROOM HEATER ar - ---
1
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 (Ql.NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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.
CHECK ONE O : OWNER❑ AGENT❑
J SIGNATURE OF OWNER OR AGENT
y� I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd accurate tot r• of my knowledge
and that all plumbing work and installations performed undar the permit issued for this application will be in corn rice with altf'"erti vision of the
,�, Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //�
PLUMBER-GASFITTER NAME LICENSE#3g1'y ' NATURE
MP❑ MGF 0 JP 0 JGF[eLPGI❑ CORPORATION 0# PARTNERSHIPy 0# LLC❑#
COMP NAME�I I[, 1-VW—i41c 1i/J�(j. ADDRESS t�2, 1"ft'3k(A-A/ G7✓' CG 1
CITY r`kJ b r tT }gyp STATE WIAry. ZIP C5 pa 346 TEL .-7 5/-�Co r'S
FAX CELL 101`7pf(-"Si kJ,— EMAIL LcLT4
ROUGH GAS IP4SFECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes N
THIS APPLICATION SERVES AS THE PERMIT 1
•
FEE: 13 PERMIT it — —
PLAN REVIEW NOTES