HomeMy WebLinkAboutMiscellaneous - 15 EMPIRE DRIVE 4/30/2018 (4) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY. MA. DATE: 7 j F`YZ PERMIT
JOBSITE ADDRESS: k;-1 �`� �ty► jJCr'C, VJMAOWNER'S NAME: C9)rAVX V,
GOWNER ADDRESS: TEL: FAX:
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES? FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER 1
FIREPLACE
FRYOLATOR
FURNACE t
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
If you have 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 Y re coverage required b Chapter 142 of the
q P
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT E]SIGNATURE OF OWNER OR AGENT
hereby certify that all of the details and information I have submitted(or entered)regarding this application are trueland accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this application will in i ce with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER/GAS FITTER NAME:.. STEPyFN C GALZNSKY LICENSE# 10345 C SI
COMPANYNAME: C,AL1►KII Pd.006106 -t- 9M- f-(hJ& ADDRESS: P.0- ROx 1701
CITY: MAVE7KHuL, STATE: ►n-A- ZIP: 01831 FAX: 521-41St
TEL: 979-3'7y- 17y3 CELL: 504- 50 - 5q0✓y EMAIL: w'vv'W• mC' 1umbe
MASTER(i JOURNEYMAN❑ LP INSTALLER❑ CORPORATION/ 31 gG PARTNERSHIP❑# LLC❑#
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
f
Yes No
G THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �Z
v
FEE; $ PERMIT#
PLAN REVIEW NOTES