HomeMy WebLinkAboutBldg-19-006938 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
II)071-4.7-7Vit
` 06. CITY q/WMA DATE PERMIT
JOBSITE ADDRESS 2i,, ff..,,
%/q�g I 'eA �. '�5 , OWNERS NAME se.6/
Gw ' OWNER ADDRESS J' v'Te TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
9"--
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--I BEM 1 ' 3 11 5 6 7 8 9 10 •11 12 13 14
BOILER --j
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT'VENT HEATER
,
DRYER
FIREPLACE i
FRYC)LATOR
FURNACE
GENERATOR I I
GRILLE
INFRARED HEATER _ 1
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER
•
ROOM I SPACE HEATER '
ROOF TOP UNIT
TEST -.
-
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
_
_ -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of I>flGL.Ch.142 YES /'NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Rr OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I any 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.
,,lll CHECK ONE ONLY: OWNER ❑ AGENT ❑
` SIGNATURE OF OWNER OR AGENT
‘z,I, I hereby certify that all of the details and information I have submitted or entered regarding this application are true c }ate to the best of my knowledge
`- and that all plumbing work and installations per-formed under the permit issued for this application will be in compf all Pertinent provision of the
,` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. l
PLUMBER-GASFITTER NAME LICENSE# 2,4110 Z SIGNATURE
MP ❑ MGF❑ JP le. JGF f❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑#� LLC❑#COMPANY NAME 'R( , C� -yea.✓" ADDRESS 137 7 44ce 14. Ji_E-y 1z
CITY 62Let ektAi� STATE 044 ZIP 02.03 2- TEL
FAX CELL 97f% Llg0-D 1 SD EMAIL littegitie444 @G °L 6 C11`44
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
064- C- eoL THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ - k
/(1/y FEE: $ PERMIT# / /,
PLAN REVIEW NOTES // �-I /•
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