HomeMy WebLinkAboutBLDG-24-167 MASSACHUSETTS UNIFORM APPLICATION FOR A PERM TO PERFORM GAS FITTING WORK
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MA DATE / Ly PEKNIT*QLDC, 24_ 1G7
(� JOBSITE ADDRESS-r1C,,k/j5 CILJ1 J c OWNER'S NAME Iy��
V OWNER ADDRESS /�//'/CJ/4 5 7 4 77 4( TEL 2�0 -lT e C) FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL Ms. EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-1 FLOORS BEM 1 2 3 4 5 6 7 8 9 10 11 12 13
BOILER t4
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
INVENTED 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 tgl NO❑
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,arid 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 in compliance th alPertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the.,eneral Laws. %q/_7/
PLUMBER-r,ASFITTER NAME M03 rib/�iC lQ Pt LICENSE# SIGNATURE
MP❑ MGF 0 JP V nJGF❑ LPGI❑n CORPORATION❑#pCo p PARTNERSHIP/ ❑*/ f1C❑#
COMPiAryIYNAME INK\ CI Ala P F1 ADDRESS Z.
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CITY t S STATE r "4 ZIP d L('/1/ TEL 7711
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FAX CELL EMAIL`S-Lj/Y26)/'•(4 c—Fjf 062 0,-)1-`411-'Ld
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