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HomeMy WebLinkAboutBLDG-19-006561 MASSACHCI ETTS LIN RM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `^` k s ' CITY MA TE PERMIT /, 6'/ 615-Cir n.. JOBSITE ADDRESS e c , ` OWNERS NAME GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT ❑ ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:' PLANS SUBMITTED: YES❑ N APPLIANCES.1 FLOORS-4 BSM 1 2 3 1 5 6 7 8 9 10 111 12 13 14 BOILER BOOSTER CONVERSION BURNER — COOK STOVE r 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 TEST ' UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER 1 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of IItGL.Ch.142 YEA NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELQW_..________..___ LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ R EsSividY E. P• OWNER'S INSURANCE WAIVER: I am aware that the acensee does not have the insurance coverage rettuhpd by, c)apt 1�gtthe Massachusetts General Laws,and that my signature on this permit application waives this requirement. M 0 CHECK C LItOWWER ❑ AGENT ElSIGNATURE OF OWNER OR AGENT 3y r.i:, 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 Pertinent provision of the `` Massachusetts State Plumbing Code and C - 142 of the General Laws. / �/ I`J PLUMBER-GASFIT IER I�lAI�4L ��j ri't I (� 1 I LICENSE# / SIGNATURE MP li, MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP r i i LLC❑# COMPANY NA E )141v 1 ( ADDRESS 67 4119(V vie' CITY c A , S Y� 4 STATE`, ZIP TEL FAX CELL S7 ` ,?l S Sa EMAIL u'n(10 e`/�©tKeos`t. 1.e7°L1 /°(T 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