HomeMy WebLinkAboutBLDG-17-003904 #43 , 1
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MASSACHUSETTS UNIFORM A.PPL.I A.TION FOR A PERMIT TO PERFORM GAS FITTING WORK
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JOBSITE ADDRESSZ./ Oa OWNER'S NAME � 1
GOWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL r PRINT
❑ R�SIDENTIAfI ,�
CLEARLY
LY NEW:❑ RENOVATION: ❑ REPLACEMENT PLANS SUBMITTED: YES❑ NO)st/
APPLIANCES 1 FLOORS—I BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 14
BOILER -I
BOOSTER
CONVERSION BURNER _ _
COOK STOVE
DIRECT VENT HEATER
DRYER __ '
FIREPLACE
FRYOLATOR
FURNACE '
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS • ?
MAKEUP AIR UNIT I
OVEN
POOL HEATER f V ®
ROOM/SPACE HEATER ECE
ROOF TOP UNIT
TEST JAN 2 4 am 1
UNIT HEATER
UNVENTED ROOM HEATER . _.
WATER HEATER .. _DI.3 DEPA-R1 MEW'
OTHER — — --_
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COV -,GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1: OTHER TYPE INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the Ii•ensee 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 hereby certify that all of the details and information I have submitted or entered regarding this application are true and a urate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued,for this application will be in oomph with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 1. e Gener l L s/ �—
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PLUM ER-GASFITTER NAME i ? II G �-*' LICETJSE#� J SIGNATURE
MP MGF❑ ;J.1...a. JGF❑ LPG!❑ CORPORATION❑It PARTNERSHIP❑#f, LLC I:#!
COMPANY ICI ME 1-14-11/7 (C ADDRESS (l 7 "`. (/`-k 4`)
CITY C•(/1C,
li' � l 5 STATE (� ZIP O TEL
FAX CELL . .---.6.6) JG EMAIL - Ct 11h CO a k:-r°L. 0--€
Ate--/ 'ft
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