HomeMy WebLinkAboutBLDG-25-633 (2) tAA ern ak\ \ t 2 bi k i\1.+
.• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK (
WWitCITY yA.r ro MA DATE l(--tY4 se— PERMIT# ,C�2206-- 7 =633
JOBSITE ADDRESS f '1Sg R'T a T OWNER'S NAME (i D 1 47 YYIf� fo/�I!'T�tS C
GOWNER ADDRESS I p6 -r ag TE()4)4 36- S S d$ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL(1i- EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 0
APPLIANCES 1 FLOORS-4 BSlul 1 2 3 1 5 6 7 8 9 10 11 12 13 1"
BOILER -----1
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER I'�
DRYER -4 a1U
FIREPLACE
FRYOLATOR
FURNACE /
GENERATOR _ I
GRILLE i
INFRARED HEATER —1
LABORATORY COCKS —i
MAKEUP AIR UNIT 1I
OVEN
POOL HEATER • 1
ROOM 1 SPACE HEATER
ROOF TOP UNIT
TEST . . - ---
UNIT HEATER
UNVENTED ROOM HEATER �~
WATER HEATER
OTHER J
I I!
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES tg NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY It OTHER TYPE INDEMNITY ❑ BOND ❑ I
• 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 0 AGENT El
SIGNATURE OF OWNER OR AGENT
s:. 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 ' ertinent ' ion of the
-- Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Lo PLUMBER-GASFITTER NAME 6earet y Ct-tk ehdr"611*S e-- LICENSE#417 t-y SIGNATURE
MP ❑ MGF❑ JP 11 JGF❑ LPG'❑ CORPORATION 0# PARTNERSHIP❑ r LLC 0#p
COMPANY NAME 6e6&Ory Seer 01 -n►604 Cetw`r ADDRESS Lit $ (46Fg /61111.C1
CITY 1*-1- )1"i °114 STATE 7MR ZIP ��613 TEI& t?1g I 7?Y
FAX CELOV .-71f_ 1 '?(I EMAIL Se I fc ea (e e 714 '9‘?" (49 m
'`Cv\ (i0 C) 63k(
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES
-,DIVI i:DN OF OCCUPATIONAL LICENSURE
• BOARD OF
PLI AND aASFITTIERS 1
ISSUES THE>FOLLtIIG L
'JOURNEYMAN PLC " .
• CRY A SELFE I
41 S/41,161GER LM
WEST YAW #' H,MA 020V341,30 z
3
28714 01E411202S 811131
LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER