HomeMy WebLinkAboutBLDG-24-578 �`" �MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITYp()L. ")Cr vle1 n _sA MA DATE 9,- it.'ip4 PERMIT# QLDG-2h-S7$
JOBSITE ADDRESS -7 5 J�m ^ -j- n � �
Sa,` r-OWNER'S N.AME5°S°-� J, i IM er-SA vx
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL
PRINT ❑ E DUCATIONAL ❑ RESIDENTIAL Er.....--
CLEARLY NEW:Ld RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑
APPLIANCES 1 FLOORS-. BEN 1 2 3 4 5 6 7 r 9 10 11 12 13 I 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS I PR - a E t -D
MAKEUP AIR UNIT
OVEN
POOL HEATER t -
ROOM/SPACE HEATER -
ROOFTOPUNIT EU4LDiaC DE'A rnatNi il
TEST 'By
i
UNIT HEATER
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 Cg'NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Lid' 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.
.3CHECK ONE ONLY: OWNER 11AGENT 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
andan 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 ca d 4t i LPertinent provision of the
Li) Massachusetts State Plumbing Code and Chapter 142 of the General Laws. )Cl\--
PLUMBER-GASFITTER NAME I2'j SC )C hs LICENSE# Z g 01 SIGNATURE
MP El MGF
MGF L� JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC 0#
COM
-ANPANY NAME S j t0 GAS �`V A-e ADDRESS l,25 TY7!-Crdv— '3t-Cs ,� 1 f C?
CITY vSce-"O-5 STATE�� ZIP °3C2' 1 TEL �l 1
FAX CELL S 78 ‘-\'1 9 0 30\ EMAIL is)4v\ �3 -"et, 4S Q cd'n ccs t'er
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT II
FEE: $ PERMIT #
PLAN REVIEW NOTES