HomeMy WebLinkAboutBldg-19-005461 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
,XLI6, CITY j a/-H-,A. MA DATE ? ,-!%q PERMIT
JOBSITE,ADDRESS 6 7 r h-e 51� OWNER'S NAME G—od ^
OWNER.ADDRESS TEL FAX
TYPE OCCUPANCY TYPE COMMERCIAL
PRINT ❑ EDUCATIONAL
❑ RESIDENTIAL -----
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-4 6SIJM 1 2 3 l 5 6 7 B 9 10 111 12 .13 14
BOILER
BOOSTER —�
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER I
DRYER
FIREPLACE
FRYOLATOR I
FURNACE
GENERATOR.
GRILLE i
INFRARED HEATER 1
LABORATORY COCKS •
MAKEUP AIR UNIT I
OVEN i
POOL HEATER
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST - . . . - ---
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 MGL.Ch.142 YES 40 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG- Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑
I
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 J
71-, I hereby certify that all of the details and information I have submitted or entered regarding this application are tru ccurate to the best o knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in corn i nc with all Pertinen 'is' n of the
�- Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ -s
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PLUMBER-GASFITTER NAME 0 a(i-i gatiOte LICENSE 43_33 p c SIGNATURE
MP ❑ MGF❑ JP L JGF❑ LPGI ❑ CORPORATION ❑fF PARTNERSHIP❑0 LLC❑4
COMPANY h ME / v(4. fi,L / ADDRESS G! AR
/
•
CITY /Gf t c.vhC ` 6
h STATE, ZIP v�- Y C.- TEL i
FAX CELL EMAIL 404 c---./1 110-1v ‘ 0 6-1444"I.1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yee No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ C� `� �� `—
FEE: PERMIT# / 74 7 �� ' /
9////7 PLAT(REYIEW NOTES