HomeMy WebLinkAboutBLDG-19-003344 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING/ v Y WORK
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`, ,s , CIT'( �/LivLl/t�l /� MA DATE rr-3 PERMIT#
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JOBSITE ADDRESS //'/ ll�=Tc - e0 OWNER'S NAME A/l�GGGS
OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALPRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO Er-
APPLIANCES a FLOORS.-4 Bsm 1 2 3 4 5 6 7 8 9 10 11 12 13 I 14
BOILER
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 I SPACE HEATER
ROOF TOP UNIT go 7657
TEST
UNIT HEATER
UNVENTED 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 ~ O ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY J/ 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.
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 cth II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. complianc
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PLUMBER-GASFITTER NAME It lc'/I49 /S4 t7 �!" LICENSE# SIGNATURE
MP MGF❑ JP ❑ JGF❑ LPG! ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME (1/427`�Gi- ADDRESS 7 / }-�4t// /' A' C-/:
CITY / IGfi'GG- STATEG'14 ZIP O,,9--G 4/1 - TEL 5'7'X.2-37 7'7
FAX CELL EMAIL M2 1,77t4f/? ,9 4/4V
'Sa
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
(94 FEE: $ PERMIT#
FLAN REVIEW NOTES.
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