HomeMy WebLinkAboutBLDG-23-9566 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
~ CITY f` -"vole-, MA DATE �b-/V- a -\ PERMIT# gL06-L_•?/ ._
JOBSITE ADDRESS a 7 l�e/i< .S.1-, OWNER'S NAMEG✓e, 1t �7G `7
OWNER ADDRESS TEL`fG4/S3S FjY
TYPE OR
f FAX
PRINT OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL er-
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:yJf
PLANS SUBMITTED:YES❑ NO❑ I
APPLIANCES Z FLOORS BEM 1 2 3 a 5 6 7 8 9 10 11 12 14
BOILER13
BOOSTER — I
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE -
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER - •
LABORATORY COCKS
MAKEUP AIR UNIT _ _
OVEN / -
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
UNTEST
IT HEATER -INVENTED ROOM HEATER
WATER HEATER - _
OTHER
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLIO 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.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER❑ AGENT El
I hereby certify that all of the details and information I have submitted or entered regarding this application are true. d accurate I.13.-: • y t edge
and that all plumbing work and installations performed under the permit issued for this application will be in compli.rice with all P ent provision.' e
yt Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBE �ASFITTER NAME LICENSE#/3�o SIGNATURE
MGF 0 �JP❑ JGF❑ LPGI❑ CORPORATION❑ItPARTNERSHIP❑# LLC❑
COMPANY NAME/ :J�G�JF4'/vt hG, . ADDRESS (_/ %/ f,/r <f
CITY S.: .C: et1e1;� STATE 17c ZIP31 c4/C0 /TEL,2 V6 77 -f
G([J f-
FAX CELL EMAILC,, r.r.,4—SCC4' 4,1c.1 •t•r
I4() 'ESS THIS PAGE FOR 1P,ISFE 'OR USE ONLY' FINAL INSPECTION 0TE
Yes N
THIS APPLICATION SERVES AS THE PERMIT
FEE: $ PERMIT 0
PLAN REVIEW NOTES