HomeMy WebLinkAboutBLDG-24-5 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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0 KO. DATE 1 71(/`6 3 PERMIT#,�G Yz•.-c7Y'S'
JOBSITE ADDRESS G/A) CCU 26 OWNER'S NAME !�I4 ('V_ c _eG rc7 i S
OWNER ADDRESS TEL FAX_
TYP
OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 6
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT
PLANS SUBMITTED:YES 0 N0,®
APPLIANCES 3 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12
BOILER 13 4
1
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER /
FIREPLACE
FRYOLATOR -
FURNACE
GENERATOR
GRILLE -
INFRARED HEATER - - - _
LABORATORY COCKS - —
MAKEUP AIR UNIT
OVEN - - F_ —
POOL HEATER R EC C I
ROOM I SPACE HEATER ,;S ':'
ROOF TOP UNIT r - '
TEST .. ��►
•
UNIT HEATER : - . -
---- --
RII1L_L'ING DEPAR MEN'
UNVENTED 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 MGL Ch.142 YES ® NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY [1 OTHER TYPE INDEMNITY ❑ BOND 0
• 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.
J CHECK ONE ONLY: OWNER❑ AGENT ❑
•� SIGNATURE OF OWNER OR AGENT
`'l, 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 applicatio will be in compliance with all Pertinent provision of the
Massachusetts Stale Plumbing Code and Chapter 142 of the GenerahLaws, l Mil `� ` .
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PLUMBER-GASFITTERNAME '\y(�Yd-E2 L i ,A r t LICENSE# xSIGNATURE
MP❑ MGF 0 JP� I JGF 0 ,LPGI 0 CORPORATION❑# +�r • PARTNERrSHIP 0 n LLC 0#
COMPANY NAME \�\� r I O� 1- ADDRESS 3 J i `G1✓c Ii) �
CITY 1� n n\ 5 STATE ZIP L�J�! r TEL 71 i I Q q
FAX CELL EMAIL . l'C rJ rrn crr&9 I L.((10,‘
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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