HomeMy WebLinkAboutBLDG-18-001492 MASSA.CEIUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`: _:;1 s CITY �� MA DATE l I f y i 7 PERMIT# �'/2 ---°'o/W
JOBSITE ADDRESS (O Q d/ / OWNERS NAME SO Cf 5 5 q ra__
GOWNER ADDRESS ‘./7 TEL S if F-/5 / FAX
TYPE OROCCUPANCY TYPE COMMERCIAL
YID ❑ EDUCATIONAL ❑ RESIDENTIAL V(
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO[i' !
APPLIANCES.1. FLOORS-4 BSM 1 2 3 4 5 6 7 ° 9 10 11 12 13 14 I
BOILER _____I
BOOSTER — I
I
CONVERSION BURNER _ _
COOK STOVE
DIRECT VENT HEATER I i
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE I
INFRARED HEATED. I
LABORATORY COCKS
MAKEUP AIR UNIT f'. p•'^ r.7, it "- 1
OVEN I
POOL HEATER F� t ROOM I SPACE HEATER i 4 4'/ 1 1
ROOF TOP UNIT
TEST e
UNIT HEATER
LINVENTED ROOM HEATER t-
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 1 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 ❑
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 ❑
•--. SIGNATURE OF OWNER OR AGENT
:`i• 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 [L JGF❑ LPGI❑ CORPORATION❑# Pro P PARTNERSHIP❑# LLC❑#
COMPANY NAME rii---
I (/o P'i- ADDRESS / v V v l y� i_c C et. �Q/
CITY �,0 .�or Ai Oc//" i STATE_ ZIP Q ‘y TEL 227'-?-/ !
FAX CELL EMAIL `5 it/4i Pl'I4c.J3 f'#r-+0,/r- /C-COita
ROUGH GAS INSpEt,'i'i0N NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
pca t. THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES