HomeMy WebLinkAboutG-18-4302 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTINGG WORFTt
k CITY MA DATE I"a S I8 PERMIT PERMIT# �X/l7 7043-'100
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JOBSITEADDRESS 184 Wes} yefvt.dutn Iw OWNER'SN.4ME TA n VlOROS
G OWNER ADDRESS �te
TEL__ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:ty-/
RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
APPLIANCES 1 FLOORS– BSM 1 2 3 4 5 6 7 s 9 10 11 12 13 14
BOILER - –
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER �
FIREPLACE
FRYOLATOR
FURNACE I
GENERATOR .,. –
GRILLE —_ Fitt CV t�lb t
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT .4'M 2013
OVEN tr ,j� T
POOL HEATER tili.ul v UtP
ROOM/SPACE HEATER ° -r-
ROOF TOP UNIT
TEST . ... . . ...._ . .. . . .._.... --
UNIT HEATER
INVENTED 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 [40 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY FE OTHER TYPE INDEMNITY ❑ 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,arid that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
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 corm• with All rtinent provision of the
ILL) Massachusetts State Plumbing Code and Chapter 142' of the General Laws.
PLUMBER-GASFIFITTER NAME I t �°n e J ens LICENSE#3t�I SIGNATURE
MP 0 MGF�y' JP 0 JGF 0 LPGI 0 CORPORATION❑41 GPARTNERSHIP 0# LLC❑#
COMPANY NAM 3PJC4 S & c Cr k C ADDRESS I "TZ
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CITY 1;c STATE [MA' ZIP 00.631 TEL 50D '`01 '63(A
FAX CELL EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
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THIS APPLICATION SERVES AS THE PERMIT 0 0
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FEE: v PERMIT N
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PLAN REVIEW NOTES
Nil
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