Loading...
HomeMy WebLinkAboutBLDG-17-002955 . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK � �_�" CIT( VQ�j�yl'Jj-�/��L MA DATE /z�.Q���,� PERMIT#40.� s, JOBSITE ADDRESS/��i4p7iP/il/ poi g VP OWNERS NAME f S‘ / pazer2 GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT ❑ ❑ RESIDENTIAL{ ' CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT`1. PLANS SUBMITTED: YES❑ 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 .1 \ FURNACE ' , GENERATOR t. GRILLE ti��� ��5 INFRARED HEATER �, I LABORATORY COCKS ` ' ,,Q.. MAKEUP AIR UNIT ( * �CQ I OVEN �� � POOL HEATER \\.,O ROOM/SPACE HEATER •k. I ROOF TOP UNIT —_, • TEST 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 NIGL.Ch.142 YE2'NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-;et 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. i CHECK ONE ONLY: OWNER ❑ AGENT ❑ "N 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 my knowledge \� and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Perti nt p "vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. c = PLUMBER-GASFITTER NAME Oc?r"`� -Q 2: 79 LICENSE#3I?5 j SI . TURE MP ❑ MGF❑ *-.{ t JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑ COMPANY NAME G.a.9471 . a75 /2 tyL/ ADDRESS Z,3.3'— GA 'v n.,, i -rc c -7 CITY � '2, 1---- f_. /t/1lj� -, STATE Alt< ZIP, ©2 ,, _ TEL �o FAX CELL EMAIL /—✓C ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES