HomeMy WebLinkAboutBLDG-20-003264 s" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORT;
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` ..s" CITY ay- ✓ MA, DATE 1 2-- 5 11 PERMIT*j-./)&-'Y -lc'5g�7
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JOBSITE ADDRESS t( 1--1✓ez..- OWNER'S NAME u'( 1) (t i
GOWNER ADDRESS SCAw-e TEL 4 11 102 -4Y1 FAX
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TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION: I-2 REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO ❑
APPLIANCES_i FLOORS BSM 1 2 3 4 5 6 7 8 9 10 '1'1 12 13 in
BOILER
BOOSTER
CONVERSION BURNER.
COOK STOVE
DIRECT VENT HEATER
DRYER
i
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR 1
GRILLE I
INFRARED HEATER I
LABORATORY COCKS •
I
MAKEUP AIR UNIT
OVEN I
POOL HEATER 1 • 1
ROOM;SPACE HEATER 4�7�
ROOF TOP UNIT •J�/-5'R '
TEST . .__ . . . . . . . ._ i,. . ..... .: _.._ 1
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1
OTHER 1
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES D ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG- 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
signature on this permit application waives this requirement.
Massachusetts General Laws,and that mypp �
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
`, SIGNATURE OF OWNER OR AGENT
71-: 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
`k- and that all plumbing work and installations performed under the permit issued for this application will be in compliance with Pertinent provision of the
-- Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER-GASFITTER NAME LICENSE 4 36 313 S SIGNATURE
MP ❑ MGF❑ JP JGF❑ LPG' ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑##
COMPANY NAME 6vW/1 11)(vm.koc ADDRESS 2-27 r`'r` 1/1-1 W....-
CITY (a 1-► 0-L-ci STATE 111'4 ZIP k.to l TEL t `? LI Rd ^ q2 V/
FAX CELL EMAIL d t 6Zvl e I�0-•- 1 li'tAt I J c L`-,----
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL If-ISPEGTI01{I 1{OTEc4
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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