HomeMy WebLinkAboutBldp-17-000359 (2) a MASSACHUSETTS UNIFORM APPLICATION FOR A. PERMIT TO PERFORM GAS FITTING WORK
`k"k''_,�,� CITY % ��r' roe r-IOJTII t MA DATE 7 I S PERMIT# /✓/l.�/')_/7-V4 ��
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JOBSITE ADDRESS yL Pc..ro OWNER'S NAME no r2.lup
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALPRINT
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CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS-4 BSIvl 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER j
FIREPLACE
FRYOLATOR
FURNACE -- --
GENERATOR, 4" .
GRILLE ..,. V
INFRARED HEATER tu.4
LABORATORY COCKS 1'
jU
_ 15
MAKEUP AIR UNIT
OVEN D ,RTMEN I l�
POOL HEATER
9 -�
ROOM I SPACE HEATER I
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 44.0 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ril• V 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 ❑
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 acc •. e ./st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp}'' e skit'- 'f4;ovision of the
Massachusetts State Plumbing Code and Chapter'142 of the General Laws. � 1
PLUMBER-GASFITTER NAME jtir,l 5/v5 LICENSE# 1 C/`y'44 ))) SIGNATURE
MP❑ MGF❑ JP E<IGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑##
COMPANY NAME ADDRESS ! I C y/3
CITY i'--19 S 1 IA 1 AA-4". h e 1 STATE ittl ZIP Cam?L) Z. TEL &v3 y- 4 /
FAX CELL EMAIL `J Ivs e 9 I4114 i L , cot„//
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
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PLAN REVIEW NOTES 6 /52 /