HomeMy WebLinkAboutBLDG-24-240 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY \ lM �1. MA7 �� . DATE U i o�y
JOBSITE ADDRESS Ve.�zP. >�
; 0� OWNER'SN.AME f PEGcr �RMIT# �,3L/✓��� :u
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G OWNER ADDRESS TELLS1)0D2I-1yjrI FAX
TYPE OR ---�
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW: RENOVATION:
�^ M. REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑
APPLIANCES 1 FLOORS BSM 1 2 3 A 5 6 7 8 9 10 11 12 BOILER 13 1
BOOSTER
CONVERSION BURNER
COOK STOVE -
DIRECT VENT HEATER
DRYER - --
FIREPLACE
FRYOLATOR
FURNACE 1
GENERATOR
GRILLE
INFRARED HEATER
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LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER -----7
ROOM/SPACE HEATER
ROOF TOP UNIT _ R� r
TEST � 4 E - -
UNIT HEATERD
INVENTED ROOM HEATER —J
WATER HEATER ` _ _
OTHER _
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I have a current l hiiiia insurance policy or its substantial equivalent INSURANCE COVERAGE
nt which meetsG the requirements of MGL Ch.142 YES Eft NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [\ OTHER TYPE INDEMNITY 0 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.
SIGNATURE OF OWNER,OR AGENT CHECK ONE ONLY: OWNER❑ 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 comp!! with Peril nt
▪ Massachusetts State Plumping Code and Chapter 142 of the General Laws. Prp Ion of the
PLUMBER-GASFITTER NAME
LICENSE#76:31. S NATURE
MP a MGF❑ JP 0 JGF❑ LPGI❑rr CORPORATION El PARTNERSHIP 0# LLC
COMPANY NAME l�a�V-r ? L rr A ADDRESS r e- ( 0#
FAX / ?STATE /44 ZIP U 1 3 V TEL
CELL L Sv`13 t i Lir O EMAIL INC/+Y t.4-a-f U✓P Co 1
t)ilG S Jg ter.r^�xf3P.f Ty0 S THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
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Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: PERMIT# •
PLAN REVIEW NOTES
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