HomeMy WebLinkAboutBLDG-25-365 ."�"-' MASSqAS LICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
., CITY %,yp"D QJ 1-1(/a MA DATE C /— PE 1IT#360 G-z r- 36,E
JOBSITECCCADDRESS /7 b a f ("',.0/1eritl OWNERS NAME ?r /CGG7, /
GOWNER ADDRESS \` /t TELJc'g Ao(-Y,..3-/fAY
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[d'
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0
PLANS SUBMITTED:YES 0 NO 0
APPLIANCES 2 FLOORS BSM 1 2 3 1 5 6 8 9 10 11 i2 I
BOILER - 13 14
BOOSTER --I
CONVERSION BURNER R E E V�� ______I— ______ICOOK STOVE
DIRECT VENT HEATER - - - i
DRYER
JUL -1 1771] 1 !
FIREPLACE - j
FRYOLATOR VI
GENERATOR _ _
GRILLE _
INFRARED HEATER r
LABORATORY COCKS _
MAKEUP AIR UNIT
OVEN -
POOL HEATER ,
•
ROOM I SPACE HEATER L
ROOF TOP UNIT
TEST
UNIT HEATER - --
UNVENTED ROOM HEATER
WATER HEATER
OTHER
I
INSURANCE COVERAGE i �
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LT7f NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er 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.
SIGNATURE OF OWNER.OR AGENT CHECK ONE ONLY: OWNER ID AGENT 0
1: I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate to the best o knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn nce with all Pakine Massachusetts State Plumbing Code and Cha Pter 142 of the Generalof the
Laws. —
PLUMBER-GASFITTER NAME / LICENSE 4 SIGN RE
MP❑ MGF�d JP\,❑ JGF g LPGI❑ CORPORATIONR ❑4 PARTNERSHIP❑4 LLC❑4
COMPANY NAMEJ40U4Mp gar- " -r/VC, ADDRESS ,R, i-ii y�4 t?.e. /� cq CITY P ir64 STATE 12l%- ZIP 09.3 6�O TEL 76 ��ta 6 6(Q
FAX CELL EMAIL . I , )-4-4N4-C 114•1 Coe
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE QN Y FINAL INSPECTION NOTES
Ys No
THIS APPLICATION SERVES AS THE PERMIT (J
FEE: $ PERMIT
PLAN REVIEW NOTES