HomeMy WebLinkAboutBLDG-19-004303 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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f 4=6 CITY V�/-� / ' (fl 0 (f g MA DATE PERMIT*f' `"/CH'U7i
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JOBSITE ADDRESS s £ & /2_ 1- ) OWNERS NAME C1(.1 i._ sj c�1 7 S c v
GOWNER ADDRESS/.1 e,LI✓/5 61,-- /1 i,)1 t-1)e--,.5_ l TEL FAX
TYPE
� OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ti
CLEARLY NEW:liK RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES A NO❑
APPLIANCES 1 FLOORS BSM 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
FRYOLATOR
FURNACE
GENERATOR
GRILLE -
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT 9
OVEN C, C U-u(
POOL HEATER r.`
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST _±_.-- 3
UNIT HEATER '
UNVENTED ROOM HEATER
WATER HEATER
OTHER z iJ 7-[/9i° i--i to pi7`-
6 L' 7-- s / oe - / .
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES IX NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ® OTHER TYPE INDEMNITY ❑ BOND ❑ I
1
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
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT 1
L 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 Chapter 142 of the General Laws. i J2 � ! n '-
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PLUMBER-GASFITTER NAME I( t Le, ' l Cl I'i LICENSE# / SIGNATUREL
MP❑ MGF❑ JP ❑ JGF❑ LPGI❑ CO PORATION❑It /no P . PARTNERSHIP❑# LLC❑# I
M (� cri/2(2 [-) /—t ADDRESS 12 �� �C Ji//' C I
COMPANY NAME 1
CITY V v i q / e'ci STATE U A l ZIP L 3 TEL 7�/7f`Y/o �/ '-
FAX CELL EMAIL 5 n j e/` •,M r r k 22 :! kL4 /L- CD/l
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
(es No
/fit ��'f� THIS APPLICATION SERVES AS THE PERMIT ❑ El
FEE: $ PERMIT#
/ h lib 7 PLAN REVIEW NOTES