HomeMy WebLinkAboutBLDG-20-000532 -. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TOPERFORMGAS FITTING WORK
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,s- CITY �I hr�cr-trite MA DATE s \7 ('‘ PERMIT / T S
JOBSITE ADDRESS \. `� 'Cs"N..t�'n"nlN`41`Kti S\-' OWNERS NAME ��1-. ' R__4 ‘,X)r.
GOWNER ADDRESS\ \--Or cc . .CS,.\i•-•-‘4t,,,., TEL FAX
TYPE OR
� � OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTP
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMS PLANS SUBMITTED: YES❑ NO❑ l
APPLIANCES 1- FLOORS-+ BSI1A 1 2 3 4 5 6 712 l
- 9 _ 10 'l'I '13 14
BOILER —�
BOOSTER
CONVERSION BURNER
COOK STOVE \ T
DIRECT VENT HEATER
DRYER _ `---_I
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER I
LABORATORY COCKS
MAKEUP AIR UNIT 1
OVEN i
POOL HEATER
ROOM!SPACE HEATER
ROOF TOP UNIT U.. ��4' ,
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 NIGL.Ch.142 YES 1 NO ❑
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 applic (.. are true and accur to tot e best of my knowledge
` and that all plumbing work and installationsperformed under thepermit issued for this application will b= •a up pliance with a€ ent provision of the I
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME r.- tN QiN C:Zits-4 ,, LICENSE# -�ykoc,\ SIGNATURE
I�A, MGF❑ JP ❑ JGF LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#:
COMPANY NAME� -Ktti.61r� .k)-'C
ADDRES.,S
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CITY `� o„v \may„ ,Is..,,V STATES ZIP O*:-\ O TEL
FAX CELN'6\ -Q 1 EMAIL C tf&\v,.,CertivvaC_''-`'DC.;t1 ,
C a \ci-\ ' too--
SOUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
• FEE: $ PERMIT#
PLAN REVIEW NOTES /1— ?0
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