HomeMy WebLinkAboutBLDG-20-002872 I S r ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT 0 PERFORM GAS FITTING WORK
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` 6_., R CIT( h4A DATE I I PERMIT " 'Od0 Va
~ JOBSITE ADDRESS ?-----3 5- 0 h ) u) OWNER'S NAME ,
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OWNER ADDRESS TEL FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL4
PRINT
CLEARLY NEW:❑ RENOVATION:, REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS--I BSM 1 2 3 1 5 6 7 9 10 11 12 '13 14
BOILER
BOOSTER
CONVERSION BURNER --
COOK STOVE _
DIRECT VENT HEATER
DRYER '
FIREPLACE
FRYOLATOR
FURNACE -
GENERATOR.
GRILLE
INFRARED HEATER —~ --1
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM(SPACE HEATER
ROOF TOP UNIT
TEST . . .. _--.
UNIT HEATER _
- (INVENTED ROOM HEATER
WATER HEATER
OTHER
0 b0 061le-1 I _
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES/1 NO ❑
I IF Y OU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELT - EVE- T�
E
LIABILITY INSURANCE POLICY OTHER TYPE.INDEMNITY ❑ t f---_BORD- _JI_-_.._-_- 1
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage re uir+cl I inalltfg1nOthe
Masvarhusetts General Laws,and that mysignature on this permit application waives this re uiremen N-
permit GK 108/ y ,
UILDINC DEPARTMENT
CHECK Ott L _OWNER 1 1--AG l .' ❑
SIGNATURE OF OWNER OR AGENT
G, I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the
llbest of my knowledge
`- and that all plumbing work and installations performed under the permit issued for this application will be in comp' rice with el erti en ovision of the
�` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Q
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PLUMBER-GASFITTER NAME LICENSE# 30 3 SIGNATURE ti4-
MP ❑ MGF❑ JP 4 JGF❑ LPG(❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Iv eiom- 5,ix,..5--
ADDRESS I a' 7 CCl' i C 1`fed i. c=1
CITY Ce n�e f-v: l/e STATE/" // ZIP 0 6 ) tV TEL 5 or 3?.Ua r
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
•
FEE: $ PERMIT f
PLAN REVIEW NOTES