HomeMy WebLinkAboutBLDG-20-004376 . L. . ,.. MASSACHUSETTS UNIFORM APPLICATION FOR A P RIUII TO PERFORM GAS FITTING WORK
`^ {' =.J C. G 1' PERMIT It nL"4lT -0"11211I(p
1s sN CITY MA DATE
JOBSITE ADDRESS IQO Ot iNER'S NAME
GGWNER.ADDRESS $,4 AA 6 TEL FAX ,--'''''
TYPE OIL OCCUPANCY TYPE COMMERCIAL❑ EDUCATIO , ❑ RESIDENTIAL
P)NT
CLEARLY NEW:D 1"`NOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO D
APPLIANCES-I FLOORS—F BSM 1 2 3 4 5 6 7 ° 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATERDRYER —
FIREPLACE 11111
FRYOLATOR
al .
■ , lsINFR'ARED HEATER .- � - f111
! ■ i
LABORATORY CO it.
ROOF TOP UNIT
ROOM/SPACE HEATER
. ..---..- -- . ---
UNIT HEATER
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UNVENTED ROOIVI HEATER LI.
WATER HEATER
OTHER I
/-
INSURANCE COVERAGE -
I have a current liability insurance policy or its substantial equivalentvahich meets the requirements of NIGL.Ch.142 YES [r'wo ❑
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
i•• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur to 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 I rtinent provision of the
�` Massachusetts State Plumbing Code and Chapter 1:62 of the General Laws.
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PLUMBER-GASFI fT ERP�AME -� ;7 LICENSE# SIGNATURE
l5 :
MP MGF EY' EW/"?F LPGI ❑ ORPOP ION❑4 PA , NIRSHIP❑#r LLC❑#
COMPANY hlA( E !� ADDRESS /-- r 4-11fl1Z /J P---P
CITY fi .WO 4 STATE --A ZIP 0'Z T� TEL cO (.) �115
FAX CELL EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR OR USE ONLY FINAL IIEISI'I;
INSPECTION�i'�O�'Eq
Yes No
6;4
J / ' /11e) x,P THIS APPLICATION SERVES AS THE PER1v1IT ❑ ❑
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FEE: $ PERMIT t6
/ Ni'fl 6/i d/ka Zgg PLAN REVIEW NOTES
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