HomeMy WebLinkAboutBLDG-23-3061 .�a'.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�iPL--_ CITY r At N`chJ\lA MA DATE ` ! PERMIT t� �c�r� 3 O%I
JOBSITE ADDRESS el 7 u 1-C wi- /i!/cm-el-A 121' OWNER'S NAME-S U 2INN/( rat i T 1-
GOWNER ADDRESS �/�/"1E TEL FAX
TYPE OR r ►
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IX
PRINT
CLEARLY NEW:❑ RENOVATION", REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑ I
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 1
BOOSTER I
CONVERSION BURNER, I
COOK STOVE
DIRECT VENT HEATER I
DRYER �
FIREPLACE !
FRYOLATOR
FURNACE
GENERATOR.
GRILLE "
' INFRARED HEATER. 1
LABORATORY COCKS
MAKEUP AIR UNIT I
OVEN i
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST X
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER : ..J.rj O i ,r' I 1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESJ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Aec 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.
CHECK ONE ONLY: OWNER ❑ AGENT!❑
SIGNATURE OF OWNER OR AGENT j
,-{,. I hereby certify that all of the details and information I have submitted or entered regarding this application are true an c to to the best - y knowledge
\� and that all plumbing work and installations performed under the permit issued for this application will be in co " nce ' ertinen vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# �c-,5J-6 SIG ATURE
MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑it LLC❑# 1
COMPANY NAME I1- 61 b a( 00 ? -- t1 ADDRESS
CITY S `- 112IY Al C t rC(( STATE"1 ZIP 0 2 U 16 TEL S - 72 6 X 2i
/4'2 ph-..as N l�ri 4 i4 3./e
FAX CELL EMAIL 03/.,CJ4_,
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yee No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES