HomeMy WebLinkAboutBLDG-18-001490 :> MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK v
`^ k 6N CITY U. I . 7 q rni au I'4 MA DATE 7 /v / 7 PERMIT#JAI?' 00/
JOBSITE ADDRESS Q i3r0461k4,v2 // OWNER'S NAME 5'0 Ss -J'O
GOWNER ADDRESS � TEL crg 76—Vj'' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
PT ❑ RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO IE 1
i
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 e 9 10 11 12 13 14
BOILER —____I
BOOSTER 1
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
1 I
DRYER
i
FIREPLACE 1
FRYOLATOR
FURNACE
GENERATOR -
GRILLE
INFRARED HEATER.
LABORATORY COCKS
MAKEUP AIR UNIT .
OVEN '"� k TM:k' -1
POOL HEATER - L s
ROOM/SPACE HEATER �� ��
ROOF TOP UNIT r I
TEST / T.}r S
UNIT HEATER : ., P ,4 i V - ----
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 Al NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 5Q 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
i
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
' 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 El JP El JGF❑ LPG' ❑ CORPORATION❑4/ ap PARTNERSHIP❑# LLC❑#
COMPANY NAME /1( l`/de �‘74— ADDRESS / A4// x/? q9 L
CITY ` , 6 .l G1 C/ni ofiti STATE �ZIP D C (� 7/ TEL ??7 77 >''/Z Z
FAX CELL EMAIL
t.lei14
---------------------- -----------------------------
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
e Yes No
o/r THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
C. PLAN REVIEW NOTES