HomeMy WebLinkAboutG-17-2333 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
" CITY _ ,#.,enl/'ls MA DATE // / /d PERMIT# ar/7--ca
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JOBSITE ADDRESS , 6 a--; /� €oc,C ski/ OWNER'S NAME STG i�//J
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL®-
PRINT
CLEARLY NEW:Erf,ENOVATION:0 REPLACEMENT: ❑ PLANS SUBMI I I EU: YES 0 NO❑
APPLIANCES 2 FLOORS—. BSM 1 2 3 4 5 5 7 B 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE / -
DIRECT VENT HEATER -
DRYER
FIREPLACE -
FRYOLATOR
FURNACE
GENERATOR
GRILLE /
INFRARED HEATER
LABORATORY COCKS .
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT NEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
nefrd/fear
INSURANCE COVERAGE
I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES gait 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 ❑ AGENT ❑
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 compliance with all Pertinent provision of the
W Massachusetts State Plumbing Code and Chapter 142 of the General Laws. m
PLUMBER-GASFITTER NAME i»rs/�7 Areite u
LICENSE#�gay SIGNA mit
MP Er MGF❑ JP❑ JGF❑ LPGI 0 CORPORATION r -7PARTNERSHIP 0# LLC❑# i
COMP• IEE irMtramiT PD�Hri/L ADDRESS // ea-47P
CITY STATE`' ZIP .176 TEL
FAX irNOv 01 2016 •ELI77y�W6678y EMAIL c1002-1941-Iree96/ cs—Sen
BUDDING DEPARTMENT
my $ 70 Z1�
•
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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