HomeMy WebLinkAboutBldp-19-006940 MASSACFHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i
-11-W„ev CITY 'r1., MA DATE t 10 I e1 PERMIT#"N-06 nte0 ��'o JOBSITE ADDRESS 7 S pinni 13,rgo OWNER'S NAME i PlFl
OWNER ADDRESS TEL FAY,
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CL E AR'Y NEW:❑ RENOVATION: {g/ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO 1
I
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 , 12 13 14
BOILER -_1
BOOSTER
CONVERSION BURNER, _
COOK STOVE
DIRECT VENT HEATER I— i
DRYER �—;
FIREPLACE I
FRYGLATOR
FURNACE
GENERATOR
GRILLE --
INFRARED HEATER _ 1
LABORATORY COCKS • l 1
MAKEUP AIR UNIT
OVEN i
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 NIGL.Ch.142 YES R6 ❑
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.
I
CHECK ONE ONLY: OWNER ❑ AGENT ElI
SIGNATURE OF OWNER OR AGENT
"l-• 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
`k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
`..-', Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE#I tR d SIGNATURE
MP V MGF❑ JP ❑ JGF E LPGI ❑ CORPORATION❑#i PPRTNERSHIP❑# LLC 52
COMPANY NAME 3iwaUGo••..e,r f Jv es a fs ADDRESS l 1-7 6rce 4 rv1-z, -L J
CITY `cr.4-crI / tC STATE ft A ZIP 0 26`3 t TEL
FAX CELL 77'1 35'3 $3G'2- EMAIL /
ROUGH 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 6
4-1
OP &PI