HomeMy WebLinkAboutBLDG-23-9448 ,` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
�, CITY /laMeuTl+ tAkt. nyl MA DATE 2 /23 PERMIT tY�L C-23 9JL/yg
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JOBSITE ADDRESS a0'/� I„/e OWNER'S NAME At VJeA(
GOVa7 ERADDRESS TEL FAX
TYPE OR —�
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION:V REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO
APPLIANCES J FLOORS 9SM 1 2 3 4 5 t; 7 8 5 10 11 12 13 BOILER
BOOSTER
CONVERSION BURNER __
COOK STOVE
DIRECT VENT HEATER
DRYER
—FIREPLACE -
FRYOLATOR -
FURNACE _ -
GENERATOR
J GRILLE
INFRARED HEATER p-t:
-1, LABORATORY COCKS 1 g
I i MAKEUP AIR UNIT
OVEN
POOL HEATER
i I ROOM/SPACE HEATER L
n,
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`,i ROCIFTOP UNIT t�_�`—c q�tNT
1,1 UNIT HEATER
414 UNVENTED ROOM HEATER
WATER HEATER
IFI OTHER
il _
II, INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [f'NO 0
III IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
III, LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND 0
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
72 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 performed under the permit issued for this application will be in compliance with at P I t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE# /(,g/p ' NATURE
MP'MGF ElJP 0 JGF❑ LPG'0 CORPORATION❑# PARTNERSHIP❑# LLC 0# SciE
COMPANY NAME Lila.r64'2 pt v .✓G ADDRESS If/Z/x lit u C:l
CITY A7rark'tee- STATE //id ZIP TEL
TEL
FAX CELL In-aAi 1a?r EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ n
FEE: $ PERMIT I
PLAN REVIEW NOTES
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