HomeMy WebLinkAboutbldg-20-000579 _I, '' MASSACHUSETTS UNIFORM APPLICATION FORA P MET TO PERFORM GAS FITTING WORK
kitio,$' CITY lgt U1 MA DATE i G r PE AIT#
JOBSITE ADDRESS 0 b//' C/`./Q OWNERS NAME atzei A / /Gi/k,
OWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
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PRINT ❑ R�SIDEIJTIAL
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [� PLANS SUBMITTED: YES❑ NO e
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APPLIANCES 1 FLOORS--I bEM 1 2 3 4 5 6 7 0 9 10 11 12 13 14
BOILER — 1
BOOSTER
CONVERSION BURNER
COOK STOVE - i
DIRECT VENT HEATER
DRYER — I
FIREPLACE i
FRYOLATOR i
FURNACE
GENERATOR
GRILLE
INFRARED HEATER I
LABORATORY COCKS
MAKEUP AIR UNIT 17) ' I
OVEN _.,_. I
POOL HEATER I--._-...
ROOM I SPACE HEATER JUL�2019 1
ROOF TOP UNIT
TEST -.. • ... . - BUILDING U�PF�RTMENT
UNIT HEATER Ely.
UNVENTED ROOM HEATER I
WATER HEATER ;-^
OTHER l
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IVIGL.Ch.142 YES V NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLIC,/❑ 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.
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-, CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
"i-, 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 corn Ii ith all P rtinent provision of the
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Massachusetts State Plumbing Code and Chapter 142� of the General Laws. '
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PLUMBER-GASFITTER NAME � r/eV LICENSE# V ifv SIGNATURE
MP MGF❑ JP ❑ JGF E LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC�#roiC
COMPANY NAME �f�l�GS � GGI� ADGP,ESS�94
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CITY L.C1' 1 E'"t STATES"1 ZIP&DI- v 3 TEL 60giatgyp`
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
t• THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ rpmt-c•
/ FEE: a PERMIT# L Al/A- 720
PLAN REVIEW NOTES
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