HomeMy WebLinkAboutG-12-627 of✓J_7r/raki,/COS-if , a'7„L
go.,- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITEADDRESSr 'i?J 0141 OWNER'S NAME 1 fen,G p f-
OWNER ADDRESS
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TYPE OR OCCUPANCY TYPE COMMERCIAL % EDUCATIONAL 11 RESIDENTIAL' -
CLEARLY NEW:( _{ RENOVATION:7 REPLACEMENT:(� PLANS SUBMITTED: YES r4 NO[ ''],.
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7vrryZj 13 14 ;
BOILER (J f I 1 t- U
BOOSTER �
CONVERSION BURNER ,, I -
COOK STOVE — -
DIRECT VENT HEATER
DRYER BUILDING-DEPT_-'_
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FIREPLACE — . ammiaml
FRYOLATOR j
FURNACE --- —
GENERATOR ,
GRILLE —
INFRARED HEATER
LABORATORY COCKS — —
-- -- -
MAKEUP AIR UNIT
OVEN .
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
-
TEST
- - --
UNIT HEATER --
— - - --- - -- ---- —-
UNVENTED ROOM HEATER
WATER HEATER - .. __.- _ -- -_-_- --__ _ -
_..
--OTHER I
INSURANCE COVERAGE
I have a current lability insurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YESN�•_
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
' LIABILITY INSURANCE POLICY IT-<-
OTHER TYPE INDEMNITY r1 BOND S_ !
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 LI 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 ' IIPertinent provision of the '
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME( Jam/ On nSa..... 1 LICENSE#iJSo/ I,..---7 IGN TURE
MPfVMGFf, JP[^ JGF[ LPGIfl CORPORATION F-7#lb_ 77? PART RSHIPE ;LLC #L_.
COMPANY NAME
:I 5110,? Iked(13 tCRrlrty 1ADDRESS�S7-44/14c R .
CITY I S_._" vr1DGk ,pp 6
1 STATE[/AjJ ZIP[ 02 6‘ .-6 Y8-a07
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FAX I_ _ . _ 1CELL i�f/527 EMAILI. . �St�!�R La�2C4Fi�l Cootl� ? cowl _ 1
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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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