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HomeMy WebLinkAboutB LDG-23-9342 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Yeti` Vv\.(9 t.L4 MA DATE CP ai a3 PER - 2 3 JOBSITE ADDRESS 9 (0 N C) r W a1-L./ OWNERS NAMEM ' �Stec C to�p OWNER ADDRESS , 1 Q�a.r` U e ✓111�/1siCU4 Y`�IA'TEL33'1 b G'? FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[11---- ?RENT CLEARLY NEW:❑ RENOVATION: ©REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES T FLOORS-4 BSM 1 2 3 1 5 6 7 8 9 10 11 L 12 1 BOILER I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE k FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN 1 R C - POOL HEATER • ROOM I SPACE HEATER T ROOF TOP UNIT2 TEST lUbl I_ 3 UNIT HEATER e u , C r�v i,r ti UNVENTED ROOM HEATER _ �Y = I WATER HEATER (� OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [a NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY 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 0 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 compli- ce wi all Perth-nt , �'�". • sled.�thofftthee Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //ff ! PLUMBER-GASFITTER NAME Ste e\A•e S5 Ck 6 k �' LICENSE# fO//p o SIGNA IRE MP gr MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION lir# Q/3 PARTNERSHIP,❑# LLC 0# COMPANY NAME At�t1/1.6r*©►�V l60/14,a M .�-�(/1 P ADDRESS 123 a ee tIP ,-Av e CITY At .1- VV� STATE n4f' ZIP 034 7Vt� r TEL7 k1, jlt(P TO 73 FAX. d /✓3 V/lee CELL33 L 3Q:O ve2 lab EMAILQ,V'\ wt, ,Eitw tC.4i I• Col ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY I+ITVAL INSPECTgON NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT ft PLAN REVIEW NOTES