HomeMy WebLinkAboutBLDG-20-002565 RMIT� IFs6
fen• MASSACHUSETTS UNIFORM APPLICATION FOR A PE TO PERFORM GAS FITTING WORK
i_i_r, CITY S•yGr1'Vi MA DATE /1/r// PERMIT# *06'oa 6-6S
JOBSITE ADDRESS 3? in d n den oq £d OWNERSG NAME_ JQ cK- (Ca✓t t
OWNER ADDRESS 3 Mona eno y I?d FAX
FAX
TYPE PE OR
PRINT OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL ElRESIDENTIAL a
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: S
PLAN SUBMITTED: YES❑ NO
APPLIANCES-I- FLOORS-4 BSM 1 2 3 4 5 6
BOILER o 9 10 11 12 1
BOOSTER
CONVERSION BURNER,
COOK STOVE -
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE I J
GENERATOR _ 1
GRILLE
INFRARED HEATER
LABOPJATORY COCKS I
MAKEUP AIR UNIT _I
OVEN -
POOL HEATER —I
ROOM/SPACE HEATER
ROOF TOP UNIT ____, '
TEST • '
UNIT HEATER
INVENTED ROOM HEATER -
WATER HEATER
OTHER ��
_ i
INSURANCE COVERAGE r
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES R( NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
•
LIABILITY INSURANCE POLICY g 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
--1., 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 compliance th all P inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# 02,017.5 S SIGNATURE
MP❑ MGF❑ JP 1 JGF❑ LPGI El CORPORATION❑# PARTNERSHIP # �^
COMPANY NAME Jac (e- (1r a►�i c ADDRESS 3 f�70»a rryi k Ede.E ; 1
CITY 5;yQ ✓tM STATE niC ZIP d 166 e1
EL NOV 01 2019
FAX CELL 56e-6tC(45-S6S'6 EMAIL
/ //�� ILDING D
ROUGH GAS INSPECTION NOTES
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
7.
PERMIT it Fr41-7)-c_
,f-f
PLAN REVIEW NOTES /(/ 7 77