HomeMy WebLinkAboutBLDG-17-001174 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
ItirUfg;
1F,)
V-Wl CITY (t-(111) . MA DATE 9 PERMIT#64-Pb-/7—&11.7(1
ss
JOBSITE ADDRESS 2 ( Otifv-P-0(1) OWNER'S NAME geti rivtC_P4
--pe-
GOWNER ADDRESS -2.(1 TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION: 0 REPLACEMENT:0 c..p 16.s4vv_e_ PLANS SUBMITTED: YES LI NO 0
APPLIANCES FLOORS--4 BSM 1 2 3 4 5 6 7 8 9 10 'I'l 12 '13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE ,
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER ad)
c4-elf2Q1
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES A...NO El
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ir OTHER TYPE INDEMNITY [I] BOND 111
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: 0 •NER El AGENT El
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application ar: e any a • et he best of kn Wedge
• and that all plumbing work and installations performed under the permit issued for this application will be in c..141i.,,"ei, P rtine provision the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '/
A Gt of
PLUMBER-GASFITTER NAME VI -/-e-0-S-A- LICENSE# 7e.,6-7 SIGNATURE
I'L) MP MGF LI JP,k.JGF fl LPGI E] CORPORATION 0# PARTNERSHIP LLC El#
COMPANY NAME IM:LiCe (A-a-al"- 5 4-#7> ADDRESS ( ik -Y
CITY STATE fr-frPf-- ZIP 02(f 6 r TEL 77(a iS1
FAX CELL EMAIL
Lit
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES