HomeMy WebLinkAboutBLDG-18-003586 #2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY /A- cf j/ M?, DATE ' 7 PERMIT# D6-/a-ew.S'2.
JOBSITE ADDRESS Ccrwr ti]u ek1+�NV OWNERS NAME ZU7 f
OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL c
PRINT [� ❑ RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-F SSIv1 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER --j
BOOSTER —�
_ I
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR _
GRILLE f
INFRARED HEATER I
LABORATORY COCKS
MAKEUP AIR UNIT afC/ '�7 f ( i
OVEN i
POOL HEATER
ROOM!SPACE HEATER
ROOF TOP UNIT
TEST 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE ,�,/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU,Ch.142 YES TKO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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.
���
PLUMBER-GASFITTER
NAME '� '.�Et/i LICENSE# SIGNATURE
MP ! �( MGF❑ JP❑ JGF❑ LPGI ❑ CORPORATION �/� / PARTNERSHIP❑# LC❑#!
COMPANY NAME 1)/, 04 `��C' , ADDRESS ( ,\3 eibASTI AdJ�p ,:-)3
CITY W IC-t-( STATE 0V(1 t ZIP TEL A- S40
FAX CELL774 /741 EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
eG / Yes No
G/" /O` /7 /( THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
1