HomeMy WebLinkAboutBLDG-17-002856 If
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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per�u� CITYIMA DATEf I7/l / PERMIT#�6 'I7— 4o6JOBSITE OWNER'S NAME
GOWNER ADDRESS TEL
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ri RESIDENTIAL kl
PRINT
CLEARLY NEW:U RENOVATION:Li REPLACEMENT:it PLANS SUBMITTED: YES CD NO►
APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER 9
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BOOSTER 7ti 1.1-.,jiLmJi:
CONVERSION BURNER 11 3 'a «, � f
COOK STOVE ,,
DIRECT VENT HEATER -73 L_ jr- I r--
DRYER i I Ji ' -- L.
FIREPLACE 1.. �a __ 1, t .
FRYOLATOR « , -.M . Ali . i. . .w�.m ,.. I _. . 1� �. f 1 _
FURNACE _ :1,-_.—II -1
GENERATOR -11 ,,may
GRILLE L JL 11 I._ IL... I L., II« :..J J m..
INFRARED HEATER J 1 mm
LABORATORY COCKS t ,., 0.„ A„.. ,n„„,,,,,-3:. -3 3- ,.
MAKEUP AIR UNIT �1 ._._ I Iw ..&
OVEN ,Ji<. ,1, 1-=11 r
POOL HEATER
ROOM/SPACE HEATER 11
ROOF TOP UNIT k; __-
ROOF
TEST N. —�—Jr_ ��
UNIT HEATER ,�i J ii D - «� i, #_. 4
UNVENTED ROOM HEATER r 1, _ i „_
WATER HEATER _....
OTHER ' s ,- ir 11_._ L 1 3 I_ f « ,
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES X NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY N OTHER TYPE INDEMNITY 0 BOND Li
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 Li AGENT
SIGNATURE OF OWNER OR AGENT
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 corn I' with all nt provision o the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME r IG Ir LICENSE itri aP SIGNATURE
MP Z, MGF LI JP El JGF D LPGI rj CORPORATION`� # PARTNERSHIP # .., LLC a., J#[
COMPANY NAME: , I _ i � f ADDRESSLc )
CITY -- ��1 � tad ._ �. STATE ZIP 1�_ . `TEL (5 op.« ..x...
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FAX i i CELL ��.x�, EMAILE
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ "
FEE: $ PERMIT# g16--
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PLAN REVIEW NOTES gft:=- /e0C`(
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