HomeMy WebLinkAboutBLDG-16-006875 .'` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
(04,7 _ 1S - ,Of/G—COaf
;�7 CITY Y0.0 rti0 v-f�'1 MA DATE �— 16 PERMIT
JOBSITE ADDRESS 7 f0. OWNER'S NAMEG
OWNER ADDRESS 1/( TA �t/r�, TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIAL
PRINT
❑
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ Tod •1,11) PLANS SUBMITTED: YES❑ NO-
APPLIANCES 1 FLOORS--4 BSM 1 2 3 4 5 6 7 8 9 10 '11 12 '13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
- —— FURNACE
GENERATOR.
GRILLE _� 1
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
I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 8 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g 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 II
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 perfomied under the permit issued for this application will be in complian 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter
142 of the General Laws.
PLUMBER-GASFITTER NAME J%1 G!Er,; al LICENSE# I6o 66 SIGNATURE
MP MGF❑ JP❑ JGF El LPG' ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME 5G' f I-b f'1 b;1,1_5 p
ADDRESS r o 13 108 6-
CITY r) 'eck51-4 qn STATE ri P ZIP o - 11 1_17 7?e->zee
-RECEIVED ;
FAX CELL EMAIL `--
JUN 15 2016
•
IN AR NT
-------------------
---------- ----------------------------
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
( C - VOL L£f 1t I1/ Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES