HomeMy WebLinkAboutBLDG-24-4 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK
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GOWNER ADDRESS i _ _ -afITqjl�l" SV'FAX"_____I
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CLEARLY OCCUPANCY TYPE COMMERCIAL,j EDUCATIONAL_] RESIDENTIALZ
CLEARLY NEW:,___I RENOVATION:J REPLACEMENT: PLANS SUBMITTED:YES 0 NO
APPLIANCES 1 FLOORS-. BEM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BOILER _i_1 I J J_ J_J_J_I _I__J( I I
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BOOSTER —J JJ, I—t�_J— __I___I —1 i, I
CONVERSION BURNER _ I I I_J_l___I__I_J__ I_1 1__ ) I
COOK STOVE _ t__ _ _ __J___ ____I____1 _I_J I
DIRECT VENT HEATER
DRYER _--J—1—J_—J_ —J�J_— J_ __I__II®��
� FIREPLACE J_ J I- I i_ _J
FRYOLATOR �___J- ! - __.1 _�� _'
J FURNACE —J_JJ'___! ±J _. ii - J_ I ' -I
i GENERATOR I t I_J_ I I >�� -
GRILLE --_i—J—J_ _J-J____I__In T!'111 J U5 ■�—I 1
INFRARED HEATER _J—JJ_I' I,_J_J 41 .�,_ Mij
OVENKUP AIR UNIT -I�—JI_1___J I in -.L AK —J_
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LABORATORY COCKS i ' - f_j
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` POOL HEATER _J-J-___J_J--I_J_._I_J—J_—J_ 1___
ROOM/SPACE HEATER - 1_I__-__L_l—J_---J I_I_J_ 1 I I I .I
ROOF TOP UNIT -__I_J___J_J_I_____1 --I�'_I_J._1__I I
TEST —I____II".i I _J_____I_i__I I_i_—II, I
UNIT HEATER _I__ l_I_ __J_".-J_J_i I: I i
UNVENTED ROOM HEATER —J—J _i__i_!,_;-_J_J__I_I_J__I__-i—J
WATER HEATER _ f __J—1_!__I____I_I__ __I__I f i
OTHER I—1 i__I_I__I I r I_1_J_:___1______I__ I I I 1 . I
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I have a current liability insurance policy)or its substantial equivalentINSURANCE
IC —J I—J I I I I
NCECOVERAGE
which meets the requirements of MGL.Ch.142 YES JNO J
0.
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY - OTHER TYPE INDEMNITY J BOND L-I
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„_I AGENT J
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 compliance with all Pertine t provision of the
Massachusetts State Plumbing Code andChapter 142 of the General Laws.
PLUMBER-GASFFITER NAME `•'i ly t -I LICENSE# ✓�4 eL k f FI SIGNATURE
MP J MGF LJ JP ifi JGF;_, LPG]J CORPORATION_j#7.----
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COMPANY NAME:f 1 8 e V --- _ I ADORE__ _ . cro i'YVT/) . I
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FAX I CELL • 'EMAIL' `_41 Al k',4 (`1� •`G M-LLB 'C t1,^1
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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
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