HomeMy WebLinkAboutBLDG-22-5159 E D QSSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY- MA DATE 3 /0 ZZ PERMIT# . 1- SISS
MAR�11 1 2 �BSfTE ADDRESS • - @ OWNERS NAME
B ILDINEi�9ENH
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PRINT UGCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[S--
CL,EARLY NEW:❑ RENOVATION:pl_
EPLACEIdENT:5---------- PLANS SUBMITTED:YES�0
APPLIANCES 2 FLOORS-r 6SM 1 2 3 4 5 6
BOILER B 9 10 11 12 13
1,
BOOSTER 1---
CONVERSION BURNER
COOK STOVE /,
DIRECT VENT HEATER --
DRYER
FIREPLACE
FRYOLATOR
FURNACE _
GENERATOR C —'—
GRILLE - - _
INFRARED HEATER - -
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER "
ROOM/SPACE HEATER
ROOF TOP UNIT _ - -
TEST
UNIT HEATER _
UNVENTED ROOM HEATER -
WATER HEATER
OTHER
INSURANCE
I have a current liabili insurance policy or its substantial equivalent which COVERAGE meets the requirements of MGL.Ch.142 YES E}'
0❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
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.
J SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT❑
a,+ 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 th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the Gene rall Laws.
PLUMBER-r,A ITTERNAME 'J I t R rU foe et(i 1, t l5gq/r SIGNATURE
MP MGF JP JGF LPGI❑ CORPORATION❑# /PARTNERSHIP❑# LLC❑#
COMPANY tO �j NAME ZtP 1 (-D f 1 ADDRESS Z i I/V 77 O Y1/ l CITY ` STATE ZIP O<7 TELD 3[Q 3 g613
FAX CELL EMAI QV-iLCI�
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT (^ _
FEE: $ PERMIT it
PLAN REVIEW NOTES