HomeMy WebLinkAboutBLDG-15-001741 % * MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
APPLIANCES? FLOOR Bsmt 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 HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ei NO 0
If you have checked YES please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICC OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:lam 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
hereby certify that all of the details and information I have submitted(or entered)regarding this application are tme and accurate to the best of my
Knowledge and that all plumbing work and installations performed under the permit issued for this applia in compliance with all Pertinent
provision of the Massachusetts State.Plumbing Code and Chapter 142 of the General Laws.
PLUMBERIGASFITTERNAM •R - ce r ' LICENSE# SI ATURE
COMPANY NAME �( - fC. - I, S� SS: ya .��2 "-ir hkt
CITY f o r STATE:'"" (O ZIP:o 3-6 ' ) FAX:
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MASTER 0 JOURNEYMIrQJ LP INSTALLER 0 CORPORATION 0# PAR ER HIP❑# LL� `#
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ROUGE!GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: S PERMIT I
PLAN REVIEW NOTES
1