HomeMy WebLinkAboutBldg-19-004373 "N.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING
`: 4R ,s CIT( V 67i1-!e'z (��U�� M?, DATE 9/ ,Z O /7 PERMIT#I �/� �T` GG 7�7
JOBSITE ADDRESS / Z- � - 4j C.� OWNER'S NAME v '1 ,rilicil,
OWNER ADDRESS f X ('`:' 0 k K TEL FAX
TYPR OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCA(trONAL ❑ RESIDENTIAL�.--'-'
PRENT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ®/ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES -1 FLOORS--4 BSlul 1 2 3 4 5 6 7 8 9 _ 10 11 12 13 14
BOILER - --1
BOOSTER
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER — 1
FIREPLACE
FRYDLATOR
FURNACE _
GENERATOR. I
GRILLE I
INFRARED HEATER —7
LABORATORY COCKS i
MAKEUP AIR UNIT
I E C,
OVEN . Li . I
POOL HEATER -� J
ROOM I SPACE HEATER I
ROOF TOP UNIT ; t 'l'�'' '
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent whi h meets the requirements of IUIOL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE. 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.
I
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT l
"‘I•• I hereby certify that all 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 compli n .with I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General aws. i
Li j
PLUMBER-GASFITTER NAME 14, --- ft//' ,� LICENSE# Z,-5-S O SIGNATURE
MP ❑ MGF n JP "�JGF❑ LPGI� CORPORATION❑# PARTNERSHIP❑��/ LLC❑# I
COMPANY NAME // 7G{/*C t®G�/ J././ a7- ADDRESS ? j'
/ 7 y �� / x
CITY MI P ,/‘, 'L-. STATE /Pq ZIP T / TEL I
FAX rE , CELL -Y 7X EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
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i/ ✓d)/9- FEE: $ PERMIT ff f V / u2 i
PLAN REVIEW NOTES ���