HomeMy WebLinkAboutBldg-20-001594 \.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1:' CITY L. MA DATEd q11 /l/7 PERMIT#/310‘' o e i s 9 y
JOBSITE ADDRESS / (/. OWNER'S NAME
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NOK
APPLIANCES Z FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE f
DIRECT VENT HEATER
DRYER
FIREPLACE I
FRYOLATOR
FURNACE
GENERATOR
GRILLE
•
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST 1
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 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 0
OWNER'S INSURANCE WAIVER: 1 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 a to the st of my owledge
and that all plumbing work and installations performed under the permit issued for this application will be in c 'th II erti provisio of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#J59O°l0 SIGNATURE
MP MGF❑ JP ❑ JGF❑ LPGI/ ❑ CORPORATION❑# PARTNERSHIP❑#I ,, LLC❑#
COMPANY NAME �. ��€XnCI J Whi/fJrU 1 Inc . ADDRESS d8 K la Fi (A
rr,,'�� f J Cab 9 r_
CITY l.V. (J (1AO/fl1 STATE �� ZIP �1 TEL �' J
FAX CELL EMAIL
��n
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY }'i FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
Nib- FEE: $ PERMIT#
4 L/,2 PLAN REVIEW NOTES
/i/zT* xi,1e7-6
le&I A-
J 2// 1611111
p,/s// ?
S