HomeMy WebLinkAboutBLDG-25-181 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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tl CITY _ MA DATE' Z " PERMIT#Vt.A6- 2-1- l iv
JOE SITE ADDRESS.I ç7 /) (i9M777- I OWNER'S NAME '
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TYPE OR OCCUPANCY E COMMERCIAL;,^) EDUCATIONAL J RESIDENTIAL --
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CLEARLY NEW: RENOVATION:J REPLACEMENT:41 .,= PLANS SUBMITTED: YES,D NO i X
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER —J ____j_J —I__I'_J-____J.____.1_____i _I 1 1111111 ..- I
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MAKEUP AIR UNIT
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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 YE KO NO :_j-
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 2] BOND Li
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 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 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 Plumbing Code and Chapter
-142 of the General Laws. ,46,4, \..A.__SL
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PLUMBER-GASFITTER NAME ! .`.ccC � rt LICENSE#1 %Olr�� SIIGGNATURE
MP J MGF JP JGF D LRGI::1 CORPORATION'# 1 PARTNERSHIP:�.1# - —I LLC:J#^ I
COMPANY NAME: ( i t -Pt*ADDRESS: -/-- i 4 ,�fzr
CITY - -- ._ ._ .......� �_4`:. ..•.. ...._... _._... _. __..
l� 3 I STATE 1 .. j ZIP( -? / ITEL (-�d ZT i
FAX -- — -- (CELL- . .._..._ • — i EMAIL' ��j n�i P� �d.0��` 9f:��eQ r - C d M -C
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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 ❑ ❑
FEE: $ PERMIT0
PLAN REVIEW NOTES
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