HomeMy WebLinkAboutBLDG-17-002439 V
MASSACHUSETTS UNIFORMAPPL€CAT€ON FOR A PERMIT TO PERFORM GAS FITTING WORK j
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4 6 r CITY /A/OA0c:iI, MP, DATE 11/7// G PERMIT#046-8-062 9F7
JOBSITE ADDRESS /s �e-&5 A ✓t OWNERS NAME
GOWNER ADDRESS TEL FAX
TYPE OR
PINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[
CLEARLY NEW:V. RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES-1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 1 14
BOILER
BOOSTER
CONVERSION BURNER.
COOK STOVE -{ —
DIRECT VENT HEATER j
DRYER
FIREPLACE
FRYOLATOR
FURNACE _
GENERATOR I
GRILLE I
INFRARED HEATER
LABORATORY COCKS I
MAKEUP AIR UNIT I
OVEN _ '�
POOL HEATER 1
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES "NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ 1
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. f
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
3, and that all plumbing work and installations performed under the permit issued for this application will be in co 'th all Pertinent tr 'sioc+-a€pe 1
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. "
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PLUMBER-GASFITTER NAME 8,,,,, T;„RI-A- . LICENSE#304 RE
MP ❑ MGF❑ JP 1‘JGF❑ LPGI ❑ CORPORATION❑ff PARTNERSHIP❑4 LLC❑11:
COMPANY NAME J 4541.7. P/ua.., 6,n y ADDRESS I D 5 Lis,.o n 5 j-
CITY)11.."-,1 Us,. ft pc..r STATE el. ZIP 0 Z 1 7 5-- TEL
FAX CELL 5q- JZZ-tree EMAIL
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
<f 04-5 Olt G De/$ //%l/(p Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ff
PLAN REVIEW NOTES