HomeMy WebLinkAboutBLDG-20-000971 - ', MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
e: :k s` CITY lralnAcjidI-frfrk IMMP, DATE b frr-V--ce l PERIv1IT#rno6-'a�'-049971
JOBSITE ADDRESS31_6A,I-A-4 ....z\_,_, OWNER'S NAME Zt r`CA,-- '-ts
GOWNER ADDRESS±31 1p L __ e . TEL ".
TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL gp
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:` PLANS SUBMITTED: YES❑ NO❑
APPLIANCES--- FLOORS-4 6SM 1 2 3 4 5 6 7 8 9 10 '11 12 13 1
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER I
DRYER __1
i
FIREPLACE '
FRYOLATOR
FURNACE _
GENERATOR. I
GRILLE I
INFRARED HEATER ____I—�
LABORATORY COCKS �_ k
MAKEUP AIR UNIT
EC:dVED- i
OVEN I
POOL HEATER i
ROOM i SPACE HEATER h I
ROOF TOP UNIT i i rqi�rro*eiro-7
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 I111GL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.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 l
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
s„I-• 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 pro vision of the
' Massachusetts State Plumbing Code and Chapter*142 of the General Laws.
PLUMBER-GASFITTER NAME V\i 'CAA &- (1\ LICENSE# 3.- e S1 SIGNAT ,
MP ❑ MIFF❑ JP g JGF❑ LPGI ❑ CORPORATION❑#F PARTNERSHIP❑41, LLC❑#i:
COMPANY NAME jn1ACNUrtin P4Ae__ nn ,4 ADDRESS7�� ;IN PMnu V2 (ih�.
CITY J,(14/i CV\ STATE "v(�• ZIP OZt 4 f TELLS '' 3a' I(,S�
FAX CELL- l-6 Z I'�J cv 9 d EMAIL MLcI' f�--1 & �✓ D' Lc✓ A
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
I+Il'^aAI,IIzIS.I'I;GTIO11NOTEc4
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT It
PLAN REVIEW NOTES