HomeMy WebLinkAboutBLDG-20-004909 CO
a
r�._.. MASSACHUSETTS UNIFORM APPLICATION FOR A PE ET TO PERFORM GAS FITTING WORK
iG s CITY yff ��fi MA DATE .6 L-v PERMIT* 6-' -011 0q
JOBSITE ADDRESS OWNERS NAME_
GOWNER ADDRESS 3 -jui li TEL FAX
TYPE OCCUPANCY T E COMMERC
PRINT L❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW: RENOi/ATI REPLACEMENT: ❑ PLANS SUBMITTED: YES NO
❑
- - i
APPLIANCES 1 FLOORS—F BSM 1 ? 3 1 5 6 7 s 9 10 11 12 113 14
BOILER _ —1
BOOSTER
CONVERSION BURNER _ -
COOK STOVE _
DIRECT VENT HEATER
DRYER
FIREPLACE '
I
FRYOLATOR
FURNACE _ I
GENERATOR I
GRILLE i
INFRARED HEATER —~
LABORATORY COCKS —~ I
MAKEUP AIR UNIT
OVEN _ i
POOL HEATER •
ROOM I SPACE HEATER I
ROOF TOP UNIT r.-
TEST _.. ... . .. . .-- - - . . ._ .._.... .. .
UNIT HEATER
UNVENTED ROOM HEATER 1i1 / ! q
WATER HEATER �J
OTHER
., ii 1 i
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 COVERA . CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ I
• OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the l
(Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑ 1
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 ac rate to the best of my knowledge 1
`— and that all plumbing work and installations performed under the permit issued for this application will be in compliance ' Pertinent provision of the
` Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER- SFITT�ME 6/V Li . LICENSE# 1�� SIGNATURE
MP , MGF❑ JGF LPGI � #❑ CORPORATION❑#>: PA,R V:R'SHpIP❑ ,, p LLC❑# 1
COMPANY N E • ��� pq-- pit
ADDRESS 2C /u i 0
CITY 0 ( STATE/'"l/ ` ZIP e,2 7 3 TEI„2/U.34 q-
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR I SFE OR USE ONLY
Il�lAI INSPECTION[NG`IE
Yes NO
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: $ PERMIT It
PLAIN BEVIES NOTES