HomeMy WebLinkAboutBLDG-24-344 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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MA DAATT� �a y PERMIT t 3")N 2 i 3yh
JOBSITE ADDRESS < / �Gln $/ /lery
Glp 3 OWNER'S NAME [/¢(S
OWNER ADDRESS ��^ CL` 7 el— TEL
TYPE OR FAX��
YET OCCUPANCY TYPE COMMERCIAL EDUC ONAL 0 RESIDENTIAL El
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:
PLANS SUBMITTED:YES 0 NO 0
APPLIANCES Z FLOORS-. BEN 1 2 3 4 5
BOILER 6 6 _ 9 _ 10 11 12 13 14
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER �'
DRYER
FIREPLACE _
FRYCLATOR
FURNACE R E C t I V k D
GENERATOR
GRILLE .ItJK 0 a 202} �
INFRARED HEATER - - _ _
U
LABORATORY COCKS Lill N NG D PARTME NT
MAKEUP AIR UNIT _,Y---
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT I
TEST I
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER /
OTHER +,
INSURANCE
I have a current liability insurance policy or its substantial equivalent nwh COVERAGEh
meets
the requirements of MGL Ch.142 YES Eel NO❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0
• OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER El AGENT El
3
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
ti and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinent pro'sion of the
Massachusetts State Plumbing Code n an Chapter 142 of the General Laws. `�/�, k//
PLUMBER-GASFITTER NAME I�Gi6 LAA( an./ LICENSE#lc-$'-fCr SIGNATURE
MP LJ MGF 0 JP pc�JGF❑ LP/GI CORPORATION❑# PARTNERSHIP 0# LLC 0#
COMPANY NAME v S (I,M�'rL ADDRESS 5-4^2- of Q4-5 (y,..Gr /2-Q
CITY Den q/ S STATE/KC ZIP CO3k--- TEL I e
FAX CELL- LI 3 s3 )/ EMAIL Il �AeS-fa (.t / 2 Ve/- al
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ROUGii GAS : cv�C ON ES
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION ERVE;AS TH1 PERTk1IT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES