HomeMy WebLinkAboutBLDG-24-631 MASS CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
c' CITY MA DATE /ll//7 z/ PERMIT# _C 17 Ce- Z4-___3 i
JOBSITE ADDRESS OWNERS NPME4/c 44 >�+4
GOWhIERADDRESS i rr TEL Zoo_‘ejrz, FAX_________
TYPE OR OCCUPANCY TYPE ❑ EDUCATIONAL ❑ RESIDENTIAL
PRINTCOMMERCIAL VI A-14-•DuP(p u
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: , PLANS SUBMI I I EU:YES E.. NO 0 1
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APPLIANCES 3 FLOORS+ SCM 1 2 3 1 5 6 7 8 9 10 11 12 13 1
BOILER tE
BOOSTER
CONVERSION BURNER
COOK STOVE /
DIRECT VENT HEATER I
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER 1 ,-,i-I. 1.l e` t D
ROOM/SPACE HEATER sr •. .
ROOF TOP UNIT TEST , oc r ,
UNIT HEATER
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UNVENTED ROOM HEATER • ALLILU,n uL1‘A,2intL1d r
WATER HEATER c,
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES (,2 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY 0 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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER❑ AGENT 0
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 appli ation will be in compliance with all Pertinent provision of the
7-' Massachusetts State Plumbing Code and Chapter 142 of the General Laws.s.p `� /11 �.�
PLUMBER-GASFITTER NAME M I CJr6 e(,M,� r i iii2 LICENSE# SIGNATURE
MP❑ MGF❑ p,JP `Fn I P CORPORATION❑# PARTNERSHIP # prop LLC❑#
COMP V NAME Iv efig"'1 ADDRESS 37 � /*o ICJ
CITY Gt A AL 5 STATE ��- JJJJZIP 4 Z60/ TEL 27y7/c 9/e2
FAX CELL EMAIL e/ . ••
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GAS �� IOrt I( ,� THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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1 OUGI
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
FLA1 REVIEW NOTES