HomeMy WebLinkAboutBLDG-24-480 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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�sd CITY 9MA DATE - 9 PERMIT# (iL06 2 t-yin
JOBSITE ADDRESS 10 22 vat "p6 OWNER'S NAME S'her/e r.1 er h r°
OWNER ADDRESS S A M•e— TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E PRINT ❑ EDUCATIONAL 0 RESIDENTIAL
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:
PLANS SUBMITTED:YES❑ NO
APPLIANCES? FLOORS 6SI4 1 2 3 4 5 6 7 a 9 10 11 12 13 1a
BOILER f
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/SPACE HEATER
ROOF TOP UNIT
TEST .. -
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 40❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY 0 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.
SIGNATURE OF OWNER,OR AGENT CHECK ONE ONLY: OWNER 0 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 knowledge
and that all plumbing work and installations performed under the permit issued for this application wit be in com 'ante with ll Pertinent pro ion(Ate
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME LICENSE#/D7S(, SIGNA RE
MP r721 MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME R, F^�`jl2 F7l Jtnt b,n S ADDRESS I Z H J m(� 7Q7c1 12Tj
CITY 'De nfl15 STATE hi 11- ZIP c3i TEL 7$1'^Z37 `72CJ�j
FAX CELL col 3/171-o.fOG EMAIL "R.F,Jce5ie cat) tvws ,�p��
ROUGH GAS INSPECTION NOTES [HIS PAGE FOR INSPECTOR USE DRILY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: 4 PERMIT ft
PLAN REVIEW NOTES