HomeMy WebLinkAboutBLDG-18-004343 • E-7 MASSACHUSETTS UNIFORM APPLICATION FOR Al E- MIT TO PERFORM GAS FITTING WORK
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CITY / a • JI4 MA DATEf e PERMIT 0,340
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JOBSITE ADDRESS //Si !). P l l OWNER'S NAME ( ,ve
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GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
PRINT
0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:'[_I PLANS SUBMITTED: YES 0 NO['
APPLIANCES 2 FLOORS-4 BEM 1 2 3 4 5 6 7 3 9 10 11 12 13 14
BOILER '
BOOSTER
CONVERSION BURNER —
COOK STOVE J
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR A
FURNACE V '
GENERATOR 4 V
GRILLE -
INFRARED HEATER G� `�\e A
LABORATORY RY NIT �' y
MAKEUP AIR UNIT t ' i/OVEN4t.:
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POOL HEATER ,;er
ROOM I SPACE HEATER 1
ROOF TOP UNIT 03
TEST ... . ... . ._ . . . ._. .. .. _._
UNIT HEATER
UNVENTED ROOM HEATER
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 P40 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY W 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.
3 CHECK ONE ONLY: OWNER 0 AGENT ❑
-.. SIGNATURE OF OWNER OR AGENT
I hereby certify that all M the details and information I have submitted or entered regarding this application are d accurate to the best of my knowledge
5- and that all plumbing work and installations performed under the permit Issued for this application will be in corn , ce J . Pertinent provision of the
•Li) Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. �,
PLUMBER-GASFITTER NAME �af'l"� LICENSE 111)/2 /al., SIGNATURE
MP MGF 0 /J/P 0 GF 0 LPG'0 C9 ORATION 0# PARTNERS IP 0 0 LLC 0 0
COMPANY NAME nit,
7 ir( )oc /j Pte-, ADDRESS %7 Iif Amt, n 7
CITY (.i'r/T`L>rli' STATE ZIP O 5 TEL OP-zn -2713
FAX CELL EMAIL , id 4 t i. T 7 0' /a E4 , i
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT# _iJ)
PLAN REVIEW NOTES /6P/A