HomeMy WebLinkAboutBLDG-16-003436 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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._i_ £11.NKIlif MO en MA DATE l PERMIT# 0-PA/b.—CPO ge/.
JOBSITE ADDRESS } l
Yrosoci- �v OWNER'S NAME(, -+I l IL•(�1�Y1 �r('�f�`C
OWNER ADDRESi✓— i,1 1 , c.--� TEL i .'1 7 L LID FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:fif PLANS SUBMITTED: YES 0 NO
APPLIANCES 1 FLOORS-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE _
FRYOLATOR _ _
FURNACE
GENERATOR •
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT _
OVEN _
POOL HEATER _
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
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 At NO 0
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 ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are t nd 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 c • nce with all Pe • t provision of the
Massachusetts State Plumbing Code and Chapter
�142'off"the General Laws.
PLUMBER-GASFITTER NAME La%r9 T. 1iC.1 l•lrY O- LICENSE# )201Cf NATURE
MPX MGF 0 /JJP ID JGF 0 LPGI El1 l CORPORATION(� �'#. PART HIP❑# LC❑#
COMPANY NAME (Tfm N umbi 06 -t1- C I ns ADDRESS 4 LU e- I i n( 'r'1 Ph
n -� nn
CITY Li CL�n STATE �.` ZIP I) OtSI..t2S i TEL I C1I ' Sti2-7-S,Mq
FAX 40) 35) •70IS- CELL - Oi " `k q• 24 6 EMAIL L"CO1)g& 9errp )LLmbin . 0Om
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r QUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
1I. ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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