HomeMy WebLinkAboutBLDG-18-001486 MASSACHUSETTS 1SETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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4 CITY / - // MA DATE PERMIT#0/4919-i`0o %//g{o
JOBSITE ADDRESS‘ 0 er040 l7 OWNERS NAME S3 ro
GOWNER ADDRESS .to �TEL 'g/5 Yi FAX
TYPE OROCCUPANCY TYPE COMMERCIAL EDUCATIONAL E_
PT ❑ ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO pil 1
APPLIANCES• FLOORS-4 BEM 1 2 3 4 5 6 7 8 9 10 11 12 •13 14
BOILER
BOOSTER — I
CONVERSION BURNER,
COOK STOVE
DIRECT VENT HEATER
DRYER �i
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR. -.
GRILLE I
INFRARED HEATER. I
LABORATORY COCKS I
MAKEUP AIR UNIT , ! 4 I ! —7
OVEN l
POOL HEATER . T i,_. ��a r'1j i 1"'
ROOM/SPACE HEATER , `�� _ _ :._—
ROOF TOP UNIT
TEST 5 4/'r_ _ . __
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER1.
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES g NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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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 ]
:`t 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. !
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP❑ MGF❑ JP [ JGF❑ LPG! ❑ CORPORATION❑# P tOP PARTNERSHIP❑# LLC❑0
COMPANY NAME I "l (_,3 /`t /0 i---/-/ ADDRESS / ` Y/ Ld e"- LA ti12.
CITY 50 Ct t M O IJ STATE ZIP D TEL y TEL 77 ySio /ZZ
FAX CELL EMAIL S/L"/n J 4C_, /k/d,
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OUGH GAS INS PECTION NOTES TNIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION I NOTES
Yes No
ail-3 CVC THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
CC/ • FEE:
$ PERMIT# •
PLAN REVIEW NOTES