HomeMy WebLinkAboutBLDG-16-000074 cA)J/,a i�r r= ,, .t�(R
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
k� CITY MA DATE /b/Sl PERMIT#/*lb/6-acc,c `
JOBSITE ADDRESS _t 1._.iti o4-Gh an+_c..3 a y. OWNERS NAME E A_Us r,w c. .. ..
GOWNER ADDRESS $ -e—
TYPE OR OCCUPANCY TYPE COMMERCIAL0 EDUCATIONAL❑ RESIDENTIAL[
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CLEARLY NEW:[ RENOVATION:[ REPLACEMENT:0 PLANS SUBMI 11 tU: YES p NOL
APPLIANCES 1 FLOORS BS'M 1 2 -3 4- 5 6 7 8 9 10 11 1 12 13 14
BOILER _ '
BOOSTER �.,_ {
CONVERSION BURNER
COOK STOVE . . I
DIRECT VENT HEATER 3
DRYER
ER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR I p
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GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
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OVEN
POOL HEATER
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ROOM I SPACE HEATER
ROOF TOP UNIT j
TEST / �, ... �,_ . -.1
UNIT HEATER
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R u t L.t.) a UAr i, —TI.f L N I INSURANCE COVERAGE
I . - , - - ..I or its sty ectfivalent witch meets the requirements of MGL Ch.142 YES [ 1/NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1-9/ OTHER TYPE INDEMNITY 0 BOND n
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requited by Chapter 142 of the
Massachusetts General Laws.and that my signalise on this pemtit vpliatkm rives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that an of the details and information I have subrrited or entered reganting the aeon are, • accurate to the•_ •
and that all plumbing work and installations performed under the permit issued for this Stan WB be in .• f•.'; .-with all -- ; - • • ----• of -
Massachusetts State f karnbkng Cade and Chapter 142 of the General Laws.
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PLUMBER-GASFITT'ER NAME LICENSE# /128.6 S c+ i -
MP MGF F..i JP n JGF❑ LPGI fl CORPORATION Ei# oZ 8-5A , PARTNERSHIP D# - LLC D# 1
COMPANY NAME 05 -L i ay-Nov/Az i4te,- 1 ADDRESS .f(v:l 09657_.u"TPi._0F�,T- _-... . . . I
CITY _ FOXgoeo. ...- --i STATE ln ;zIP 07.1455..._.. TB. 31�b'T3'S��= j/
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FAX --f9 rEMAIL. 60
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Pb/1 04-4 Dot 4j2l/ 7/ 1/5" Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ CI
FEE: $ PERMIT#
PLAN REVIEW NOTES
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