HomeMy WebLinkAboutG-13-726 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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T"' -tin. ' PERMIT#
4` ; MA DATEI 1 1 .�o L
e+? I® CITY
JOBSITE ADDRESS IM OWNER'S NAMEn n P ASS
G TEIt$15 -301-6415a IFAX
OWNER ADDRESS
TYPE OREDUCATIONAL❑ RESIDENTIAL
PRINT OCCUPANCYNPE COMMERCIAL❑ PLANS SUBMITTED: YES(] N0�
CLEARLY NEW:p RENOVATION:0 REPLACEMENT:Gli
APPLIANCES T FLOORS-' 8 9 10 11 12 13 14
BSM 1 _ 2 3 _ ��, ---,--, _ - -111--5 6 7 _ I I
BOILERBOOSTER I p� � 'i i®
CONVERSION BURNER 4 1
COOK STOVE
--_._I� I .- '�- -_I r— i- �. S I
DIRECT VENT HEATER j
DRYER ; I�
FIREPLACE .
FRYOLATOR • A I
FURNACE 4 ,
GENERATOR ' ; I i
GRILLE ;
INFRARED HEATER L-
LABORATORY COCKS : JI L_
MAKEUP AIR UNIT . ,
OVEN
POOL HEATER .a,r
ROOM I SPACE HEATER
ROOF TOP UNIT `
I .
TEST :
UNIT HEATER
UNVENTED ROOM HEATER
WATER _. _:
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OTHER 1' I I f I
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INSURANCE COVERAGE
I have a current liability Insurance policy
or its substantial equivalent
which meets the requirements of MGL.Ch.142 YES 0 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certifyll that all of the installations and ns performed
dI under the permit Issued for lit application will tomitted or entered regarding this application 'r•e •.II:andca ell Pertinent provision of the
that all plumbingState work
and iCodea nd ha 142 of the General Laws.
Massachusetts State Plumbing Code and Chapter
PLUMBER•GASFITTERNAME ICNRIS BR144.5
LICENSE# a9ts 1 SIGNATURE
MP® MGF❑ JP 0 JGF 0 LPG'0 CORPORATION®# ,rublillil PARTNERSHIP❑#I I LLC❑#I
COMPANY NAME:I1R tCC 5 k B ' pa.446-r- I ADDRESS I P O . eg5 X 5 3$
�1 1 STATE r1'1A- ZIPI0at3a ITEL IC�1 : ■ Y i i :1R`W1
CITY I( .i<t1'TER u rt_t.E II'���I
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FAX 508-175-0 CELL� i r I n
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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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