HomeMy WebLinkAboutBLDG-23-9770 _ `• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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ter`_'_- CITY PR Ybr a MA DATE IZ-"/�!—a;i PERMIT#tik 06-Z3` Y 77 0
JOBSITE ADDRESS p?Lf-Zakii ,Z4re S r y/9✓'wt E OWNER'S NAME Q,,,tS>2ce h t i/C(S
GOWNER ADDRESS a Y► iii 9r yi,c l.-,25 TEL e2A.3O414- FAY
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:itli PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS-4 BEM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER K
BOOSTER
�. CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER .
FIREPLACE
CP FRYOLATOR
N FURNACE '
GENERATOR
E. GRILLE R t l V 1.
INFRARED HEATER
GRILLE
LABORATORY COCKS
MAKEUP AIR UNIT • 1 9
OVEN --_
1 POOL HEATER • 4` D PARTMENT
ROOM I SPACE HEATER B -._ _ -
ROOF TOP UNIT —____I
• TEST .._-.- -- -- ---
, ' UNIT HEATER
i INVENTED ROOM HEATER •
1 WATER HEATER L__
' OTHER
INSURANCE COVERAGE
q I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 121 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
A LIABILITY INSURANCE POLICY [V 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 I . my signature on this permit application waives this requirement.
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• ;e:':- CHECK ONE ONLY: OWNER 0 AGENT ❑
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SIGNATU- /a F OWNER OR AGENT
4, I hereby certify that all of th/etails 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 Pert I-. provision of the
,�� Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ���
PLUMBER-GASFITTER NAME LICENSE#i! I `NATURE
MP( MGF❑ JP❑ JGF❑ LPG'❑ CORPORATION❑# PARTNERSHIP❑# LLC 12#
COMPANY NAME 116595 4►*U Yl04p ADDRESS 30( L-KT5 (
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CITY wa54--tin/tit, o STATE Ailk ZIP 7�� 9-3 TEL 3 i.65//�"f 2-
FAX CELL , �7I IZ BZ EMAIL imao_lrA11� ��t C�6wi
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT f#
PLAN REVIEW NOTES
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