HomeMy WebLinkAboutBLDG-19-002725 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
rinr45a CITY UA r VIAIL AA MJf DATE •I� l S I l� �' n'
1 a PERMIT
JOBSITE ADDRESS Z.3 -L{-aau is (S1 va OWNER'S NAME�IO-v \`e_�C
GOVJNERADDRESS y TEL FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIALEDUCATIONAL 0 RESIDENTIAL'H
PRINT ❑
CLEARLY NEW RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 1 FLOORS-. SSM 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 I
GRILLE
INFRARED HEATER • R r[
LABORATORY COCKS �• v _-5
MAKEUP AIR UNIT
OVEN Liuy 2718
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT nintsING DEPAFSTME T
sr
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-S NO 0
IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY-Er 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 0 AGENT 0
ti SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are d : to to the best of my knowledge
`3- and that all plumbing work and installations performed under the permit Issued for this application will be I co r}��;a rgue it provision of the
W Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �11 r
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PLUMBER-GASFITTER NAME LICENSE#kts-tZ SIGNATURE
MGF 0 JP, ❑ ❑ LPGI 0 CORPORATION❑# PARTNERSHIP❑4! LLC❑it
COMPANY NAMEVl�l- V t, ? ,kj—i- ADDRESS-?n . o J ,/ -
CRY CA I U& \ E
STAT _ Zlrr 2A q
g5 TEL 7, -iNc (1x.1'7'/
FAX CELL EMAIL IL4W(IS1 ti . �✓✓7 • �y
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT
PLAN REVIEW NOTES
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