HomeMy WebLinkAboutBLDG-25-136 "' ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�� / MA DATE '3---5"--g 5— PERMIT#81-0 G-2 r- )5 f.
JOBSITE ADDRESS I S 5QRAc,e g+- OWNER'S NAME•Qau e,_rl S i 1 w4:
GOWNER ADDRESS 6 d2t.r�rs ee St 2r1'e'. 1 &V1 TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2----
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:I2' PLANS SUBMITTED:YES 0 NO 0
APPLIANCES'3 FLOORS BSM 1 2 3 4 5 6 7 6 9 10 11 12 II
13 is
BOILER
BOOSTER
CONVERSION BURNER '
COOK STOVE f —I
DIRECT VENT HEATER
DRYER
FIREPLACE 1
FRYOLATOR
FURNACE
GENERATOR —J
GRILLE
INFRARED HEATER —1
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST _....rer� 'AR' I
UNIT HEATER r'�;MI r, V•-
UNVENTED ROOM HEATER ' � I•; • III
WATER HEATER TMali
OTHER
6 1101; D RTM NS
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 2".....------
i OTHER TYPE INDEMNITY❑ BOND 0
OWNER' SURA AIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1
Al u tts G aral Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0—AGEl+lT In
-� SIGNATUR F OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc to to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corr�pli�nce ail Perlin n of the
-"' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /(/
PLUMBER-GASFITTERNAME C Lf.'5 4.`,--42--- LICENSE#fol.3301) S RE
MP 0 MGF 0 JP JGF 0 LPGI 0 CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Po'r"e 7 L ADDRESS '+oT/ 5'e 4 raa p.&. ,fit
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CITY Cw r 5 STATE/11 ZIP Gd,_- d ?( 1 TEL 3'i 43 6 6Y€'/
FAX CELL EMAIL '' PI,.m 6+✓ 4 ./(i
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION ,OTE
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $ PERMIT #
PLAN REVIEW NOTES