HomeMy WebLinkAboutBldg-16-005479 (�eVOOW)
-, ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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;i " CITY ,/ 67///i MA DATE- P 4 --/c PERMIT# 16.
JOBSITE DDRESS 3/ie- /�fil: c OWNER'S NAME ui,../d,0710: kr,r
OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL ktr. EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT: 1K..- PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—F BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 14
BOILER
BOOSTER _
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
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 MGL.Ch.142 YES ei<1 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ 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 d accurst he best my ' krf.qe
and that all plumbing work and installations performed under the permit issued for this application will be in com ante wit ' n rove '.. . l'e '
Massachusetts State Plumbing Code a hapter 142 of the G eral Laws. 0'PLUMBER-GASFITTER NAME 41/ Zip- o LICENSE# SIGNA URE
MP❑ MGF 0 JP El JGF❑ LPG(❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
/COMPANY NAME C?, �*�_47 ADDRESS S�� �.0.���_ .,
CITY p �E I � E D
rf: STATE__ _ ZIP TEL
TEL— -FAX CELLLJ „?9..2 o ', EMAIL APR 08 2016
BUILDING DEPART'NENT
By.
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
le Jedit 6W GaC 1.-217 rie00 Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ F-Z-w/l/t-- 4 /fr-5
FEE: $ PERMIT# 0 t( 7E
PLAN REVIEW NOTES ?i/i/A