HomeMy WebLinkAboutBLDG-20-000651 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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a A DATE A/(T -/ PERMIT* ' 17KO 616
7-r . JOBSI E ADDRESS 3 OWNER'S NAME FAr(c. ./1/
GOWNER ADDRESS c..c://1 n TEL.508 8O2678 FAX
F YPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
PRINT
RESIDENTIA�SIDENTIA
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:X PLANS SUBMITTED: YES❑ NO f
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APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 0 9 10 11 12 •13 1,,
BOILER 1BOOSTER
CONVERSION BURNER
COOK STOVE -
DIRECT VENT HEATER
DRYER
FIREPLACE i
FRYOLATOR !
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS !
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MAKEUP AIR UNIT I
OVEN i
POOL HEATER
1
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
rift iElVED
LINVENTED ROOM HEATER •WATER HEATER
OTHER -
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES MNO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY XP OTHER TYPE INDEMNITY ❑ BOND ❑ 1
• 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.
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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 acc rate to the best of my knowledge
` and that all plumbing work and installations performed under the permit issued for this application will be in oomph c ertinent mkt'
Massachusetts State Plumbing Code and Chapter'142 of the General Laws. !
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PLUMBER-GASFIT'fER NAMr- LICENSE 6106 SIGNATURE
MP ❑ MGF❑ JP X. JGF❑ LPGIGI❑ 1 CORPORATION❑# PARTN�RSSHIP❑# LLC❑#
COMPANY NAME -- ZgJ I� ADDRESS 8 aefroz� �777�
CITYG'v// s<C/`Vi .2 se c STATE/04 ZIP a 26V- TEI;C°6C7 2 g762
FAX CELL EMAILaTe a)°<1cc7, C/ .
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL NSPEGTION NOTES
Yes No /NFL �-C J • d� Q
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MIT 7
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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