HomeMy WebLinkAboutBLDG-16-003668 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
y�_-='G ' CITY, '6A+2040U� MA DATE PERMIT# U1 a'
G JOBSITE ADDRESS ) O/ ////b De. OWNER'S NAME 45el` gekelr Cr Y(
OWNER ADDRESS 116 C , 1 cketkoo TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 111 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM f SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATERt.
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V 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
I hereby certify that all of the details and information I have submitted or entered regarding this application are true cur to to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corripli c •th II Pertinent provision of the
Massachusetts State Plumbing Code and LC_hapter 142 of the General Laws.
PLUMBER-GASFITTER NAME ?e$ . ` " LICENSE# 2.4140Z SIGNATURE
MP❑ MGF❑ JP pd JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME -a4 ADDRESS , 3 7 P, act rP'idc ► reo
CITY 6044:leititi Vl l STATE MA ZIP (324 3 2 TEL cfr- 1 rv` '7 Z
FAX CELL EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
/'ar/71 a/4-g n ,e9 .i// Yes No
THIS APPLICATION SERVES AS THE PERMIT El
FEE: $ PERMIT#
PLAN REVIEW NOTES