HomeMy WebLinkAboutBLDG-19-3126 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Trn S'ith , A_4T MA DATE I, r� '9 PERMIT#19-106-5)-0094%
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JOBSITE ADDRESS i a it Al W/Z At OWNER'S NAME
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW;0 RENOVATION:0 REPLACEMENT,' PLANS SUBMITTED: YES 0 NO h
APPLIANCES Z FLOORS-+ 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
GRILLE
INFRARED _
LABOR R V i= f
ID HEATER
COCKS
MAKEUP AIR UNIT
OVEN gal orertt
POOL HEATER •
ROOM!SPACE HEATER B 11LDIt•G DEPARTMENT
ROOF TOP UNIT BY _ —
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 NO 0 •
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 12CI 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,
•
CHECK ONE ONLY: OWNER ❑ 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 corn lance with all Per: -nt provl o;�.f the
,-- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i
PLUMBER-GASFITTER NAME LICENSE#fiJ8rag SIGNA
MP MGF❑ JP JGF❑ LPGI 0 CORPORATION #V-0670 PARTNERSHIPRT0# 1 LLC❑#
COMPANY NAME
/� /9.14 (. /746- -CoOL`.U'M) ,Z N.DRESS a� S<'/J-' ��Q-10
Y 1/9t
CROMEIVL / STATE 424--ZIP0 701-# TEL TEL -73779,40 I
FAX ' CELL l- 74440 EMAIL S a IA A
v . or/
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# rL ' 1/1//w 6/71 (kr
PLAN REVIEW NOTES