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Home My WebLink AboutBLDG-25-638 1 -- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ,,_ ;, `'• CITY �/1 D MA D J� �� PERMIT# 6—ZS` , JOBSITE ADDRESS _ C LL, ER'S NAME E i l L—/ OWNER ADDRESS 314-itte TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL IDEDUCATIONAL ❑ RESIDENTIAL©----------- CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:Q— PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER . COOK STOVE DIRECT VENT HEATER _ DRYER J FIREPLACE _ FRYOLATOR FURNACE _ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS • MAKEUP AIR UNIT OVEN POOL HEATER KV 18 -Th25. ROOM I SPACE HEATER ' ROOF TOP UNIT TEST . ..__.. __ __ UNIT HEATER _ UNVENTED ROOM HEATER . WATER HEATER OTHER /74t.51 f ,(— �/� • n-4..... i" 4M';l441 A (io CR Q A, ' 'C -r�/C-J IN NCE COVERAGE I have a current liability insurance policy or its substantial uivalent which meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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. CHECK ONE ONLY: OWNER 0 AGENT 0 3 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 ccurate 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 th all Pertinent provision of the 14.) Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-G ITTE AME 7 LICENSE it 7,7/76 SIGNATURE MP MGF P JGF LPGI 0 CORPORA ION❑# PARTNHIP 0# LLC 0# y9-�� P 4(i ADDRESS 2-1W l /o"`iVCO MPANY NAME 1+O��" I CITY yy tx_ "I 0 r H STATE ZIP O U [ 3 T L,-6? 56 C3 9 T✓ FAX CELL EMAI / 0 05 • ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES MMI0 LTE 1:30 July 14 Ittie 1218 PN1 • . .z=1,0;"!: = - 2 . • • - r__*1 4///aNNONHONgi/MONMAMS.