HomeMy WebLinkAboutbldg-18-002979 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
• �w-w- r CITY 5o yiq F-n-in,,L/ MA DATE / -/7`/ 7 PERMIT f f Db/ 0O //�i'
JOBSITEADDRESS 7a CA'S ags-c OWNERS NAME m0
GOWNER ADDRESS TEL FAX
TYPE OR
P1i1RIT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 4[-
CLEARLY � ❑
NEW:, CI {er RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES I NO I
1
APPLIANCES-.l FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 'I'1 12 •13 14 I
BOILER ---1
BOOSTER _�
CONVERSION BURNER �'' I
COOK STOVE / ,
DIRECT VENT HEATER /�
DRYER
FIREPLACE ( IN l' r I I
FRYOLATOR '
FURNACE
GENERATOR efi4 h u E I V 1 I
GRILLE _... s i
INFRARED HEATER '; 1
LABORATORY COCKS l7 �� k j
MAKEUP AIR UNIT s 1 1 ` I
OVEN F-3(J 1 uC o } 1 I
POOL HEATER i
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST I '
UNIT HEATER
LINVENTED ROOM HEATER -
WATER HEATER
OTHER I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YESJ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I OTHER TYPE 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.
CHECK ONE ONLY: OWNER ❑ AGENT El
SIGNATURE OF OWNER OR AGENT
; :. I hereby certify that ail 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 Pe ' ent rovision of the
Li) Massachusetts State Plumbing Code and Chapter.142 of the General Laws. �
PLUMBER-GASFITTER NAME LICENSE# o36'��c/ c SIGN
MP ❑ MGF❑ JP 0- JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#:
COMPANY NAME —Ret ' Jt)1 a P//, �C j ADDRESS 33 du e.e.4-i 0irn t ?�
CITY ` 4 44 CJ STATE 0 ZIP .0 a 4 VS- TEL 77�/83/ —3S
✓ �} 90
FAX CELL . { EMAIL
tief 4 41)
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
(es No
J4laC THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
/// (/( FEE: $ PERMIT#C
PLAN REVIEW NOTES. 6//9
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