HomeMy WebLinkAboutBLDG-23-9396 `A 0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY YA U Kant�'11 MA DATE )"3:1-$).04-7 PERMIT 6 Z -
JOBSITE ADDRESS 112 //(1_3111C),11s, .$F[b k OWNER'S NAMEi 1{r4T6 Y'y J� ps i
GOWNER ADDRESS D b ilk,r-tl/n sr TELShY $C)—a3.3FAX______________
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL '
PRINT
CLEARLY NEW:A' RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES® NO❑ j
APPLIANCES 7 FLOORS-, BEM 1 2 3 4 5 6 7 8 9 ill 11 12 13 1_
BOILER ---7
BOOSTER
CONVERSION BURNER,
COOK STOVE _
DIRECT VENT HEATER
DRYER _
FIREPLACE /
FRYOLATOR
FURNACE I
GENERATOR. /
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN —
POOL HEATER R ~ R V r 0
ROOM I SPACE HEATER I ty
ROOF TOP UNIT JU� 7
TEST .. .. -
UNIT HEATER _ f
LINVENTED ROOM HEATER „�:r.v;_nT
WATER HEATER I C ____F_—
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES lij NO 0
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 General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
; 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 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 time
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LI} r191'PLUMBER-GASFITTER NAME SnW OJb1NC+ovred- LICENSE#71167 GNATUR
MP TX MGF❑ JP❑ JGF❑ LPGI 0 hCORPORRATION®# PARTNERSHIP❑# -/�U-C❑B
COMPANY NAME'TOW not I .0jl� Y t 14 ADDRESS r2)9 /I"iO \6-D'PJ t2 L
CITY_ )- 0J[i r (J USTATE�{/� ZIP C)/S/g . TEL -}
FAX J CELLJOJ / I ��I�7 EMAIL f A c.lc tlN/a 11`6,�� 1wC� 0 d `t
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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FEE: $ PERMIT#
PLAN REVIEW NOTES
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