HomeMy WebLinkAboutBLDG-18-001144 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING,WORK 1
e fi h MA DATE C/3C'// PERMIT#j� /? "Qo/l CITY , h . u,.
JOBSITE ADDRESS 3 / F Ih ri 7�(p OWNERS NAME r P 6/;775 op,
OWNER ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 27
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: [7 PLANS SUBMITTED: YES❑ NO❑
APPLIANCES FLOORS-, BEM 1 2 3 4 5 6 7 5 9 10 11 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 I
ROOF TOP UNIT
TEST TJ . ._ -
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 tVIGL.Ch.142 YES 'NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er 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 J
"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
`— and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.Li_it
PLUMBER-GASFITTER NAME X-_✓ cc by- LICENSE# 3vb fI SIGNATURE
MP ❑ MGF❑ JP Er—JGF❑ LPGI ❑ CORPORATION❑#F PARTNERSHIP❑it LLC❑#I
COMPANY NAME f "- St-ff� !'/^^ S' S ADDRESS CG3 cz.„ S�
CITY , — '-c�/4 ��/ STATE 11e15 ZIP 0 2-6 75 TEL
FAX CELL .5)$- 2-t-``4`c/ EMAIL
ROUGH GAS INSPECTION EC I ION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTEg
R-27/ '
(e� No�!� THIS APPLICATIONSERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
' PLAN REVIEW NOTES
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