HomeMy WebLinkAboutBldg-19-006527 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I
`.7 r CITY fkj 4 r' -y--A MA DATE c//7/q PERMIT#/i)e5 "129 0,07
JOBSITE ADDRESS to cj/ .7 G/ti r (,t/1p y-(1o�vr) OWNERS NAME / " ` vrr-4.1�r"'hc-t2
G OWNER ADDRESS \
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TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL®•---- EDUCATIONAL E RESIDENTIAL E
CLEARLY
NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 4I FLOORS--F BEM 1 ? 3 4 5 6 7 2
9 1i1 I'I 1 I3 14
BOILER
BOOSTER ____1
CONVERSION BURNER
COOK STOVE / I
DIRECT VENT HEATER
DRYER --I
FIREPLACE I
FRYOLATOR
FURNACE
GENERATOR I I
GRILLE
INFRARED HEATER —� —7
.LABORATORY COCKS —� !
MAKEUP AIR UNIT
OVEN I
POOL HEATER
ROOM/SPACE HEATER I
ROOFTOPUNIT ECEIVED
TEST
UNIT HEATER
UNVENTED ROOM HEATER MAY 1 An y
WATER HEATER
OTHER QEPARTMFNT
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MCL.Ch,142 YES 'NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 11 OTHER TYPE INDEMNITY ❑ BOND ❑
i
tOWNERS 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 mysignature on this application!Naives this requirement.
permitply
I
CHECK ONE ONLY: OWNER ❑ 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 a 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 corn I€ c.with all Pertinent pr ion o'the
Alt.
Massachusetts State Plumbing Cod nd Chapter 142 of the General Laws. � i
PLUMBER-GASFITTER NAME a(it'd) 0 G-04 LICENSE# / 6 75 SIGNATURE
MP ! MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#! I
COMPANY ICI ME �—�/�{ ! 7 Al ADDRESS r 0/ 6 ePv-P-e sst AlhAt /0
7'�`u/�-t'�i ,1/,"� c../ r !
CITY
STATEiv�T ZIP O�- 6 / TEL
FAX CELL EMAIL +0sr 4-r 1/hv 0'6 ‘ g306-i a//
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No ��
THIS APPLICATION SERVES AS THE PERMIT El ❑ 6:,49
FEE: $ PERMIT ft
PLAN REVIEW NOTES `' .c/7/