HomeMy WebLinkAboutBLDG-18-004126 `----= r I ACF6l1 ETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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' --c,sH I�4?, DATE Z 3�1 ' PERMIT* / t� �
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JOBSITE,SDDRESS 3/ Di-t_ o��� , OWNER'S NAME PAtnSC 1AOt9C. E'-
GOWNER ADDRESS >j j by to TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL DU ATION.AL
❑ E ❑ RESIDENTIAL
PRINT
CLEARLY NEW:,A RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 •13 14
BOILER ____I
BOOSTER
CONVERSION BURNER 1
COOK STOVE
DIRECT VENT HEATER �_____I
DRYER - I
1 i
FIREPLACE 1
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER.
LABORATORY COCKS EcityrE
MAKEUP AIR UNIT
OVEN r -I I
POOL HEATER i JA,� 1' I {
ROOM I SPACE HEATER I
ROOF TOP UNIT ----
TEST Uf�r ! .� ,.,,
r
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 111GL.Ch.142 YES 2 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TI-IE 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
11
Massachusetts General Laws,and that my signature on this permit application valve;;this requirement.
I
CHECK ONE ONLY: OWNER AGENT ❑
SIGNATURE OF OWNER OR AGENT
‘;-.1,-, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur to t the best f my kno. e g
`- and that all plumbing work and installations performed under the permit issued for this application will be in compile e wit II Pe 'nen f the
`' Massachusetts State Plumbing Code and Chapter'142 of the General Laws.`It
PLUMBER-GASFITTER NAME LICENSE#/7(,t,o 7 SIGNATURE
MP I I MGF❑ JP 'r:; JGF El LPG'nU CORPORATION El#i PARTNERSHIP❑# LLC El#COMPANY NAME ►M t 1-s��^- ��v' "(L. ADDRESS cl 'f' ( dam SY-
CITY 1,4'4-
r3.A L‘„.T-0 `t— STATE 'll& ZIP 0 Z-(66 e TEL Sok-7C /S. !o
FAX CELL EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
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THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft
g-A(//8 PLAN REVIEW NOTES