HomeMy WebLinkAboutBLDG-18-006042 \T''"•• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`7� n-P�'. CITYYii-12- MA DATE $ a-2h F PERMIT# Pi-o6/6/X 6169"
JOBSITE ADDRESS C6 2- 6Role.....> OWNERS NAME La KE -Ciyg,
OWNER.ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL- (
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NOV
APPLIANCES 1 FLOORS—+ BSI 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 I
FRYOLATOR
FURNACE _ .
GENERATOR. I
GRILLE '
INFRARED HEATER
LABORATORY COCKS _
MAKEUP AIR UNIT
OVEN AL h
POOL HEATER I
ROOM ISPACE HEATER t0 i
ROOF TOP UNIT _. .
TEST
UNIT HEATER
UNVENTED ROOM HEATER I
WATER HEATER
, OTHER I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of IIIIGL.Ch.142 YES\NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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.
I
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT 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
3- and that all plumbing work and installations performed under the permit issued for this application will be in c p lance with all P inent pr •0 n of the l
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n
PLUMBER-GASFITTER NAME LICENSE# /'YI RS)e SIGNS4'i•URE
MP`I MGF❑ JP7 JGF❑ LPG! ,❑ CORPORATION V# �" !ci' PARTNERSHIP❑# LLC El#
COMPANY NAME f LT'/"(- 77/?i'6 Ct')C.,3C C /,/r,/6j-- ADDRESS i d int'2./ c c$ ,L
CITY y /9_4td STATE ( -'ZIP dg� i.--)--- TEL ` '� �237" 0Ui
FAX CELL 50R--� s`6 EMAIL /d",/47 <'. ps gl�e4,L. (,,m,
b
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
4