HomeMy WebLinkAboutBLDG-20-004338 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
L``rt=, CITY JT� K iv, MA DATE 2 ,- PERMIT# !*-Pb- X V
JOBSITE ADDRESS 7 7 bi/ /ond 4--f OWNER'S NAME l e
OWNER ADDRESS TEL — FAX
---
TYPE OROCCUPANCY- E COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO e/
APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 8 9 10 VI 12 13 I 1-h..
BOILER
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER
DRYER I
FIREPLACE
FRYOLATOR 11:1'',.
FURNACE / 4471
`�.
GENERATOR.
GRILLE ' ,.
INFRARED HEATER fii^`
LABORATORY COCKS \\\
MAKEUP AIR UNIT --'= R .I
OVEN
POOL HEATER • Y/
ROOM I SPACE HEATER '
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER •
WATER HEATER /
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
1-• 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 all Pertinent rovi ' n of the
\-c, Massachusetts State Plumbing Code and Chapter 142 of t e General Laws. /e�/�
'LA) /
PLUMBER-r SFITTER NAME 4((/ 7pa -S LICENSE#ffee7 SIGNATURE
MP ! MGF❑ JP ❑ JGF LPGI❑ CORPORATION PARTNERSHIP❑# LLC❑#
NAME —D-'� rl ADDRESS `0 AOX 7�.
COMPANY �luc�l�r �} ,
CITY//1/1 117 /1' STATE PWT� ZIP 19 0 TEL JCS r J/ 7 3 r
JAW FAX C CELL EMAIL a 4isl M / , CGd4.1
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY I+II*!AI mSI'EC IoN I GTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
• FEE: $ PERMIT#
PLAN REVIEW NOTES