HomeMy WebLinkAboutBLDG-15-000343 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
MA DATE: 2 PERMIT# $4Ob�S OGr1��r/j
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G JOBSITE ADDRESS;;_33 �£/nc01r'r S F I Q i R J OWNER'S NAME °.w._.9,A . - . _._.
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OWNER ADDRESS � �. --�
TYPE OR OCCUPANCY TYPE COMMERCIAL- EDUCATIONAL' : RESIDENTIAL,(
PRINT • --CLEARLY NEW:_ RENOVATION:! i REPLACEMENT: i PLANS SUBMITTED: YESLi NOL.,:
APPLIANCES? FLOORS BSM 1 2 3 4 5 6 7 8 9 to 1t 12 13 14
BOILER MO ;moSNMSSIM _
BOOSTER - S _ f S— u
CONVERSION BURNER _ Siisasi ._ -
COOK STOVE .iial
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I DIRECT VENT HEATERS
DRYER SIONIMIESIONEEMEINOMPSWAINEMEINS_
I FIREPLACE MNSS
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FRYOLATOR .. SSSM -
• FURNACE11011.1111--SitWellerlillalltillallintel
GENERATOR EMOSKINISSISIMINSOSIONSWINI
IEMINSIMMIOLWS tileiel .
INFRARED HEATER 'i l s L � L --
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LABORATORY COCKS sm _
MAKEUP AIR UNIT UMS .
OVEN e S —a-_. _JT :
POOL HEATER - 0. 61.1-1i SIMINSINO-
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ROOM 1 SPACE HEATER _ _ ssSISSSS -
ROOF TOP UNITInialli _ —gassr� f --
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WATER Ivaip�, • 3113 - --4 et- _ _ - -1 SM j .
OTHER: - i n IM —S
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-BUM I'1 N6VJ " ttvi ENT— . -. _ S SIN S C
l�L{1� t INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YEW NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY :j BOND L_'?
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 r,AGENT '..
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and infomtation I have submitted a 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 vntva ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ---.) 'l,t`, � ,t
PLU MB ER-GASF ITTER NAME`ki R AQC 1 l-' a UCENSE#r L SIGNATURE
MPX- f MGF:' JP: JGF LPG'r i CORPORATION' #a}?7C 1 PARTNERSHIP l. =#t — —,LLC 7#'."___
COMPANY NAME:11.-t ri).Wei tiaciADDRESSt 23 e,L.nce i,xgF _.._--•,__-._..J,-_.._.
CITY -1&1T ifII t ---------1 STATE mA, IZIP'S?7E 2_ITELiS -(- :;i Set -:_
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FAXS�i��fi_�S�O'CELLi .__•__ REMAIL'_ �. -.
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES .
Yes No
I THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
— — —_-.... ---- — ..-- -- FEE: $ – ---- PERMIT H_��
PLAN REVIEW NOTES