HomeMy WebLinkAboutBLDG-18-007060 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
SC-"r-- -1
te e CITY W Va{x/16 u/rh MA DATE 4 -/2-..- / O PERMIT#,-..06/3-GV7
JOBSITE ADDRESS a 't 3- .c�am///L ' OWNER'S NAME �/"/C(A? tC-q//G' to1--
GOWNERADDRESSvzO/q'CI7 i /& ;'SdU/�l`oriq Coati Yd-o`o/ ea lJ
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL✓'❑ RESIDENTIAL 111-------
PRINT
CLEARLY NEW:pa,...--RENOVATION: 0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO( __._
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR / ;a
GRILLE
0.
INFRARED HEATER
LABORATORY N , 4\�f
MAKEUP AIR UNITIT `��6G/ ��
OVEN <p
POOL HEATER . 'Q\ 2
ROOM I SPACE HEATER t\ ' > '
ROOF TOP UNIT
TEST ._. . . . . .. . ._ ._ .. . . L � ---
UNIT HEATER 4
INVENTED ROOM HEATER
WATER HEATER ,
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL Ch.142 YES 13;816-0
I P YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0/ 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.
J 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 e and accurate to the best of my knowledge
S- and that all plumbing work and installations performed under the permit Issued for this application will be I. .Ilance with all Pertine oviston of the
L‘, ,bMassachusetts State Plumbing Code and Chapter 142 of he General Laws. / . r/CJ
PLUMBER-GASFITTER NAME U4Mrs ,E Sss LICENSJE�# � ��SIGNATU
RE
MP❑ MGF❑ JP❑ JG- LPG!/❑ CORPORATION❑di PARTNERSHIP❑#/ LLC❑#
COMPANY NAME - A • /SS/ / ��i /, ADDRESS P- D - i77 r53 _l
art,/(44'717C l0// , STATE✓", �• ZIP 7/7K0 / TEL 4�,3 ffbst-
FAX ELL EMAIL
1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No •
/n
LS O % THIS APPLICATION SERVES AS THE PERMIT 0 0
i C L�
FEE: $ PERMIT# /CZ'
/ / / ,PLAN REVIEW NOTES e®;
•
•
- 1