HomeMy WebLinkAboutBLDG-15-004206 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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o cam` MA DATE; I /5 PERMIT# 1 b—/0--DC�f�(16
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JOBSITE ADDRESS!3') rm i +rcm Dr?t)e i OWNER'S NAME ; ( -G
OWNER ADDRESS ' TEL!5 -760-687 S- ;FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL, ' EDUCATIONAL F ' RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:#, REPLACEMENT: PLANS SUBMITTED: YES';_11 NO
APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
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DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR ==;€
FURNACE ...
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GENERATOR
GRILLE '
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT , ,
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OVEN
POOL HEATER „
TEST i
UNIT HEATER
UNVENTED
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WATER HEATER_ � it
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INSURANCE COVERAGE _
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES L NO Li
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.
CHECK ONE ONLY: OWNER nw1 AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true an. ' 1,ate-to-the best o y knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli. r all Pertinent p ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ._...,_ .. .._.
rr �qz� ..'S ;LICENSE#R-.l sci SIGN' U
CORPORATION rit
MP; MGF JP JGF LPG! ; i3 i P' - NERS P I# LLC �#
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COMPANY NAME' I.) 'Plum kj` 4- .1: `'‘.: "T„ri-I ADDRESS y co. D, C nen-: . ...
CITY ; _ ZIP ) TEL
FAX :CELL 'EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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