HomeMy WebLinkAboutBLDG-23-9616 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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� �q, CITY y�r^�li.A..� MA DATE 11 11 0j PERMIT I3LPX'13'5�
JOBSITE ADDRESS f 1 %a f Lk OWNERS NAME 7:
h:ck V b I,..\...4 I
GOWNER ADDRESS TEL(t a_v of al 786-1 FAX_
TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALE4
CLEARLY NEW:0 RENOVATION:EL REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO I II
APPLIANCES 1 FLOORS BEN 1 2 a 5 6 7 9 10 it 12 i
BOILER 12 1E
BOOSTER - -
CONVERSION BURNER
COOK STOVE I -
DIRECT VENT HEATER -
DRYER
FIREPLACE I
I.
FRYOLATOR
FURNACE -
GENERATOR
GRILLE
INFRARED HEATER —
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN -
POOL HEATER • 7
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST .. . R.E c C i V C n
UNIT HEATER /
UNVENTED ROOM HEATER 'g�
WATER HEATER NOV 1 A?
OTHER
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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 0 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 0
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 0
•-. 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 th est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In once with Pe e pr on of the
• Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# 763d NATURE
MP t MGF 0 JP 0 JGF 0 LPG!0 CORPORATION❑It PARTNERSHIPh� 0# LLC❑#
COMPANY NAME t\ �` Ih� i 1 ADDRESS 1'a t'vv....fro....froaS]Tot it't
CITY p'�nti STATE M� ZIP D1 a TE( &)3 b Y-9 VI
FAX CELL EMAIL `bn`Raq v/II Co oi.G4 5"/1'•✓l'•P•
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yeas No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $ PERMIT ft
PLAN REVIEW NOTES