HomeMy WebLinkAboutBLDG-24-83 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`,'' CITY LC--)Er 2G ill MA DATE / — "0.
s7„s" PERMIT#QC�G-24 Q3
JOBSITE ADDRESS OWNERS NAME/GOWNER ADDRESS ids .5r4 LI Sif f✓/e)/ TEL S1Z)a-32/?'>q �,.�
TYPE OR F7��—
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 13—
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO❑
APPLIANCES 1 FLOORS-. 6JA 1 2 3 4 5 6 7 8 9 10 11 12 1
BOILER 13 14 I
BOOSTER I
CONVERSION BURNER
COOK STOVE i
DIRECT VENT HEATER
DRYER
FIREPLACE i
FRYOLATOR —1
FURNACE C
GENERATOR
GRILLE
INFRARED HEATER _
LABORATORY COCKS _
MAKEUP AIR UNIT •
OVEN R F+. 1 V n i
POOL HEATER
ROOM I SPACE HEATER 3 0 717.act _
ROOF TOP UNIT I t -
TEST - L-_ - -
-
UNIT HEATER r wri-F)+NGGL�PART,:ENT--
UNVEIJTED ROOM HEATER B`-
i
WATER HEATER
OTHER
II have a current liability insurance policy or its substantial equivalent which COVERAGENCE
meets the requirements of MGL.Cft.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA Y 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.
ti SIGNATURE OF OWNER OR AGENT CHECK ONE 0 LY: OWNER 0 AGENT 0
�� I hereby certify that all of the details and information I have submitted or entered regarding this application are t nd accurate to the 4 T
and that all plumbing work and installations performed under the applicationmy knowledge
permk issued for this will be in co all P tine ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _
PLUMBER-GASFITTER NAME LICENSE#
SIG f(V
MP❑ MGF❑ JP 0 JGF[(LPGI❑ CORPORATION❑It PARTNERSHIP 0# LLC #
COMPANY NAME A PU 0
!, '`IY+OG �EA� ��C' ADDRESS �i. �'/�r�yr4/�� I��•
CITY /lyMoo� r, STATE/ 4.4 ZIP t5a7Co TEL ren-1�'WOB
FAX / CELL I-74'7-S'q/k EMAIL AN4AL FGeitAG 0)6411rf}jL. (O pv\
57)—6 v—
ROUGH GAS INL__--51--•'E':1—:1-----€)TEj. THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTiOi J NOTES
'des NO
THIS APPLICATION SERVES AS THE PERMIT I ( I ]
FEE: PERMIT ft
PLAN REVIEW NOTES
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