HomeMy WebLinkAboutMA_BLD_Gas_Fitting_v3_20191002_063434.pdfMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY PERMIT #MA DATE
OWNER'S NAME JOBSITE ADDRESS
TEL
October 02, 2019
121 CAMP ST UNIT 1 RICHARDSON ELAINE
YARMOUTH
4 CHARLESGATE EAST #802 BOSTON MA 02215G
BLDG-20-001781
OWNER ADDRESS
NEW:REN0VATION:REPLACEMENT:PLANS SUBMITTED:YES NO√√
OCCUPANCY TYPE COMMERCIAL RESIDENTIAL √TYPE OR
PRINT
CLEARLY
FIXTURES FLOORS →10 11 12 13 14 6 7 8 9 3 4 5 BSM 1 2
BOILER
BOOSTER
CONVERSION BURNER
1COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
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
OTHER DESCRIPTION:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.YES NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER OF INDEMNITY BOND
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.
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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
LICENSE #PLUMBER-GASFITTER NAME SIGNATURE
MP JP CORPORATION #PARTNERSHIP LLC#
ADDRESS.COMPANY NAME:
CITY STATE ZIP TEL
FAX CELL EMAIL
√
MGF JGF LPGI
√
Shane Gleason 15470
#
SHANE GLEASON 32 LAKE DR,
SOUTH DENNIS 026602838MA
√
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
THIS APPLICATION SERVES AS THE PERMIT
Yes No
FEE: $PERMIT #
PLAN REVIEW NOTES
ROUGH GAS INSPECTION NOTES