HomeMy WebLinkAboutG-20-3047 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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� �a CIT`( ,�,.., k i ✓Q I MA DATE /( •ZS'1 PERMIT
JOBSITE ADDRESS / i & (r/ 7 OWNERS NAME 7 ( e 4
GOWNER ADDRESS TEL FAY,
TYPE OF
PRINT OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ❑ RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 7 FLOORS-4 KM 1 , 2 3 4 5 6 7 8 9 10 11 12 I 1 F
BOILER
BOOSTER
CONVERSION BURNER —~ ---__
COOK STOVE
DIRECT VENT HEATER � -,
DRYER L______
FIREPLACE i
FRYOLATOR
FURNACE _ I
GENERATOR
GRILLE
INFRARED HEATER —1
LABORATORY COCKS —_ I
MAKEUP AIR UNIT f
OVEN • -
I
POOL HEATER i
ROOM;SPACE HEATER 1
ROOF TOP UNIT 1
TEST -. -
UNIT HEATER
UI'4VENTED ROOM HEATER •
WATER HEATER 1 i
OTHER
INSURANCE COVERAGE -
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. 1 h f. GEE I *ED
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ���
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ B 1> 4 20 2019
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage requires b qh4 ,y ie-I E r
iMasvachus. is General Laws,and that my signature on this permit application waives this requirement. Y _ -4"4.��__ y�
y ✓ k'` �— 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 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 co li nce with ail Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 1r42 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP I MGF❑ JP ❑ JGF❑ LPGI❑ CORPORATION❑#r PARTNERSHIP❑# LLC❑#
COMPANY NAME K(1' Fr t4- ADDRESS
CITY ►VtN S 1/1 L_ STATE 144.2 ZIP D 2-4 7 TEL , /D 639 0z Si2-
FAY, CELL EMAIL O
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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• FEE: $ PERMIT{I
PLAN REVIEW NOTES /" g /1/l"Q/' 6
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