HomeMy WebLinkAboutBLDG-20-003187 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
L s" CITY MovrkwILeX MA DATE PERMIT# nA (%•-aO 001117
JOBSITE ADDRESS \ ` \\,_ 4 v\t, ‘..,8 OWNERS NAME Fsk_ Crt-,VAR
GOWNER ADDRESS TEL \--3Vn'°\35-"y I
TYPE OCCUPANCY TYPE COMMr CIAL❑ EDUCATIONAL ❑ RESIDENTIAL V
PRINT
CLEARLY
NEW:❑ RENOVATION: I REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS—+ BSM 1 2 3 4 5 6 7 9 10 'I'I ® '13 14
BOILER
BOOSTER
CONVERSION BURNER
______,
COOK STOVE
DIRECT
DRYER
FIREPLACE
ffi FRYDLATOR
FURNACE
GRILLE
INFRARED HEATER ■ ■ -�
•
OVEN
, MAKEUP AIR UNIT
ROOM I SPACE HEATER
ROOF TOP UNIT i / 141 v 6,), ft/I
UNIT HEATER .
UNVENTED ROOM HEATER ii,
WATER HEATER 1 OTHER
I
. I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE' GE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X 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
ty Massachusetts General Laws,and that my signature on this permit application wives 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 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 co pile ce 'th all Pertinent pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i '
PLUMBER-GASFITTER NAM: LICENSE#jno-6, SIGNATURE
MP ❑ IMF❑ JP JGF❑ LPGI❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME G\\\5'►.,,\ Q\. k ADDRESS 4 I
CITY _ wrs STATE +"VI ZIP OXIC0 TEL 5-'�`E�,: \fs\
FAX CELL Sat 41rZi° N EMAIL l .na .Co�
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
� THIS APPLICATION SERVES AS THE PERMIT a a
/�Z-1°//— G y FEE: $ PERMIT#
t` PLAN REVIEW NOTES