HomeMy WebLinkAboutBLDG-19-006558 _ , r'. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
<. . . CITY `'lam .. .
:� r MA DATE I.._..._ ��J , PERMIT#/*a a24
JOBSITE AD RESS „ OWNER'S NAME 0.,Li In'i naht ' , ... ��.,.-_.G ..
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 1 EDUCATIONAL RESIDENTIALX
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:X PLANS SUBMITTED: YES; NOX
APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER 'IW
COOK STOVE : .. .
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER __._
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER i f.
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 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
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 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 conI with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /t 1 C1/4.J J�/�
PLUMBER GASFITTER NAME" ErIG T"" V\Jh l ej LICENSE# 15100 SIGNATURE
MPX MGF JP JGF LPGI CORPORATION # PARTNERSHIP'. # LLC #
COMPANY NAME I/�, V � 1 `, �.___. .. .__.... ..�.___ �......�...�._...
lQ1 J h1 t �1�� ADDRESS ViUd a I
CITY t �1C v STATE ', mA ZIP �(D �' W TEL
FAX CELL IEMAIL
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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