HomeMy WebLinkAboutBLDG-18-003094 MASSACHUSETTS UNIFORM APPLICATION€CATION FOR A PERMIT TO PERFORM l 9 GAS FITTING WORK
`' t,�§. CIT( ("AA, MADATE /i- 2 — /7 PERMIT#' Ur'-�e' d0�
JOBSITE ADDRESS 6&S H,-trZaNL.S QR . OWNERS NAME
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PST ❑ ❑ RESIDENTIAL 0�
CLEARLY NEW:�R.ENOVATION: PLANS SUBMITTED: YES ❑ ❑ ;
❑ REPLACEMENT: ❑ NO
;
APPLIANCES T FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 l
BOILER
BOOSTER
CONVERSION BURNER l
COOK STOVE
DIRECT VENT H iEATER i
DRYER,
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR.
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT ' _:w E C L 1 VE D
OVEN f �..�
POOL HEATER
! _ f ryI
ROOM/SPACE HEATER IlFqArtITL -
I ____
ROOF TOP UNIT . `s
TEST . e , tat:. ,• , ,.ke,.
a
UNIT HEATER ,..A. �:.
UNVENTED ROOM HEATER
WATER HEATER
OTHER 4
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of litIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO1'ERAG-EY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ 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.
t.
1
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT j
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in oomph e with all Pe in nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#/p?jive,. 5 GNATURE
MP I Pv1GF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION ❑# PARTNE SHIP❑## LLC❑#
COMPANY NAME /��I LrcH; i g -ply - ij tq • r0 • ADDRESS .�6o ola.��3 ��'
CITY - R►°r�l.�tAv STATE VW\ • ZIP TEL TEL 51,9 -52.2 -3D (Li
FAX CELL EMAIL how-
ROUGH GAS It'IS�I1� I IGI�I I I3I I ,S THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yee No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES