HomeMy WebLinkAboutBLDG-23-8804 MASSACNUSETTS UNIFORM APPLICATION FOR A P MIT TO PERFORM GAS FITTING WORK
CITY V MA DATE PERMIT ,_ �3 'a,(jt�
‘4907-'S ,
JOBSITE ADORE
1; AiG 0 NNER'S NAME
OWNER ADDRESS 6 TL
TYPE OR FAX
PRINT OCCUPANCY TYP COMMERCIAL❑ EDUCATIONAL
0 RESIDENTIALQ...--------
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑
PLANS SUBMITTED:YES❑ NO❑
APPLIANCES 3 FLOORSS-{ BSM 1 2 3 4 5 6
BOILER7 t3 9 10 11 12 1_
BOOSTER _
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER = i
-
DRYER
FIREPLACE
FRYOLATOR I
FURNACE _ _I
GENERATOR
GRILLE ��
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT •
OVEN _
POOL HEATER - - - —=1
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST _ �1.___
UNIT HEATER
UNVENTED ROOM HEATER ,r /Y� • — _ _
WATER HEATER� , J / _ MAY 24 N231
OTHER IK 1e i -
�J O ft C Ht H,f UM�hT I
- By
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES k NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LV 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 pennit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
J SIGNATURE OF OWNER OR AGENT
a 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 wl all Pertinent provision of the
' Massachusetts State Plumbing Code-nd Chapter 142 of the General Laws.
LU ///
PLUMBER-GAS ER NAME LICENSE 4 /�/ //_ SIGNATURE
� � • (�J
MP GF.2 J JGF ��//JJPGI 0 CORPORATION❑ti PARTNERSHIP❑ff , /LLC 1
COMPAIJYN ME��J �� /�/� yL-r JTIT6� 1 K
CITY ��V \!((J v ( ADDRESS 2/ <
STATE s"r ZIP ' 73 n TEL 0' ✓QJ# ?✓
FAX CELL EMAILMgif •114 1 1 • CL) 0 '
/ / ,6-6 I
'tOUGII 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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