HomeMy WebLinkAboutBLDG-16-000106 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
it u r
.-,:ttU 1- Y CITY c. LITH V A+.I1r, --9-1 MA DATE 6, a3 1 S 1 PERMIT#/O6'/� O)C'
JOBSITE ADDRESS 11 nOR TA-- j : i I O OWNER'S NAME f')p Re,.. 14 Li?r~_i,; 1-Z.
GOWNER ADDRESS I TEL(017—ass ( ,,b 1FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL a
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED: YES❑ NO
APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 111111111111 M_N MINI NIP UN OP 11111•1011,aa1mmi
1 Bo ii 11 1 ' '
BOOSTER
CONVERSION BURNER
----------
COOK STOVE
DIRECT VENT HEATER I I I
DRYER I
FIREPLACE
FRYOLATOR I
FURNACE M INN
''
GENERATOR �_
GRILLE � ��i�RI i����II ��1
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM 1 SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER Ill.'MN'nit NMI NE NE
NVE ' �� 1��lr i-r,
WATE' *illiPli
� 111'
OTHE. = / ■
IINN — nu - - p min —INN Mt
—
''I I INN'muma I M''MRM N—MR
BY // V A INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LINO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ID OTHER TYPE INDEMNITY ❑ BOND El
OWNER'S INSURANCE-WAIVER:-!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
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 compl ce with a rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . �
PLUMBER-GASFITTER NAME Chris Briggs LICENSE# 12901 I GNATUR
MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION 0# 3238 I PARTNERSHIP❑# LLC❑#
COMPANY NAME:Briggs&Heino Plumbing&Heating Co., Inc ADDRESS P.O.Box 538 I
CITY Centerville I STATE MA I ZIP 02632 TEL 508-778-0816 I
FAX 508-775-0404 CELL ,EMAIL rbrjhj@aoi.com I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES -i
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
1
J
-
I
J
•I
-1
jl