HomeMy WebLinkAboutBLDG-18-000789 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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h`^"'�k-_'�.r. CITY YNi✓T../GfgU�`X v G /6'(IAA, DATE PERMIT# fs'��d
JOBSITE ADDRESS C ��)� Biel('II/S 2/1/1 OWNERS NAME C/ ✓1 L/d G
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OWNER ADDRESS C.e', TEL TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL
PRINT ❑ EDUCATIONAL 0 RESIDENTIAL III
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMI I I EU:YES 0 NO 0/
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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
FURNACE
GENERATOR
GRILLE
INFRARED HEATER. I
LABORATORY COCKS
MAKEUP AIR UNIT I
OVEN -
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST f ..--- __ —
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE 1r
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch,142 YES-D NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
• OWNERS 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 CHECK ONE ONLY: OWNER❑ AGENT 0
•� 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 Imcwledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all B inept provision of the
Massachusetts State Plumbing Code an Chapter 142yhe General Laws. G /J„
PLUNGE GASFITTER NAME a.ey-va 0 LICENSE S GNATURE
MP we MGF 0 JP 0JGF❑�LLPGGI 0
00RPORATION❑# PARTNERSHIP 0# LLCEJt 5'/
COMPANY NAME/W) /Vlwi/9jj/6/ £ ADDRESS/12Il /t/ /ZAcT42,,V/!-I 4' STATE/ � � ZIP�V �'); TEL P'FAX CELL EMAIL Q/L
ROUGH GAS INSPECTION NOTES THIS TAGS FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
674s cir THIS APPLICATION SERVES AS THE PERMIT U
FEE: $ PERMIT ff
C O PLAN REVIEW NOTES