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HomeMy WebLinkAboutBLDG-20-000945 �• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMFT TO PERFORM GAS FITTING WORK `' — NC73, , MA DATE - JOBSITE ADDRESilik 6(4 1 s-P-I OWNERS NAME 4 �ts,40 GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[ PST CLEARLY NEW:Er RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES FLOORS-+ BEM 1 2 3 4 5 6 7 8 9 10 '111 12 13 14 BOILER ■ — 1 BOOSTER ■■ j CONVERSION l3URIdEP, i COOK STOVE —I— j DIRECT VENT HEATER i DRYER i FIREPLACE -- FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATERIII I LABORATORY COCKS MAKEUP AIR UNIT OVEN l POOL HEATER II ROOM I SPACE HEATERlol ROOF TOP UNIT TEST -.. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _�- OTHER I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [60 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lll 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 s -• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and urate tbest of my knowledge `~` and that all plumbing work and installations performed under the permit issued for this application will be in complian 'th II t I vision of the `t Massachusetts State Plumbing Code and Chapter 1 42 of the General Laws. , PLUMBER-GASFITTER NAME A oksse LICENSE#7910 SIGNATURE MP❑ MGF❑ JP Ly' JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME \,--Z) (.v M1\4< ADDRESS �O D)C-- l`O- CITY U ` f STATE utAA ZIP ©��t.k.) TEL - FAX CELL c -2C)8 CO13 0-)EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY F'Il*1A.I.,INSPECTION c' Yes No He/j 6// Of( THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ `- // ON FEE: v PERMIT# PLAN REVIEW NOTES il