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HomeMy WebLinkAboutBLDG-23-11931 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ynK v r7° 7/7" MA DATE/d Q- a 3 L/�/ /l PERMIT#8�r0/6-27-//93/ T JOBSITE ADDRESS 1 /o v 6 F'Z /36z W4 R'S NAME OWNER ADDRESS .4"Ptf ,Rea-goo-girl FAX TYPEOR PRINT OCCUPANCY TYPE COMMERCIAL❑ E UCATIONAL❑ RESIDENTIALX CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED:YES❑ NO 0 APPLIANCES 7 FLOORS-. BSki 1 2 3 4 5 F 7 8 9 10 11 12 13 it BOILER BOOSTER CONVERSION BURIJEP, COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR - FURNACE GENERATOR - • GRILLE • INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER • - - ROOM SPACE HEATER ROOF TOP UNIT - TEST .. UNIT HEATER UNVENTED ROOM HEATER - WATER HEATER / OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MM..Ch.142 YES 0 NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ 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 permit application waives this requirement. CHECK ONE ONLY: OWNER❑ AGENT❑ 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 Pertigent vtsio of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C7�V// PLUMBER-GASFITTER NAME LICENSE#l�8'V 3 L �NATURE MP 0 MGF❑ JP u JGF❑,�I LPGI❑ CORPORATION❑# PARTNERSHIP❑is LLC❑# COMPANY NAME/ j'//1'/Ti7/?`"/9/ ADDRESS �� 61 6 CITY Sd t)7/J/ //p7t,Qu>/G/�/ STATE ZIP ©.7‘‘ TEL O A'G2 3 7 5-6 yq FAX CELL EMAIL/47J P./21/K%rn o?oa'.s r h?S ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes 149 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • • FEE: v PERMIT ft PLAN REVIEW NOTES