HomeMy WebLinkAboutBLDG-18-002756 .; '. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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`.�:t�.6 CIT( a' C/� h1,� DATE � FERIA
JOBSITE ADDRESS C/7 F fgiff SfL 61 OWNERS NAME C/ — ,,(y
GOWNER ADDRESS -5-G«e TEL FAX
TYPE OR
OCCUPANCY TY COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑
APPLIANCES 1 FLOORS BSItn 1 2 3 1 5 6 7 8 9 10 11 12 13 I 11
BOILER
BOOSTER
CONVERSION BURNER ,
COOK STOVE
DIRECT VENT HEATER _
DRYER
_
FIREPLACE '
FRYOLATOR I
FURNACE ?
GENERATOR.
GRILLE I
INFRARED HEATER
i
LABORATORY COCKS
MAKEUP AIR UNIT i
OVEN
POOL HEATER
ROOM/SPACE HEATER. A 34 -'
i
ROOF TOP UNIT
TEST
UNIT HEATER
LINVENTED ROOM HEATER T I
WATER HEATER
- I
OTHER I
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY C . {NG THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ I
• 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 complian .with all Patti it provi 'on "the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. V
PLUMBER-GASFITTER NAME LICENSE# zss'ro SIGNATURE
MP ❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME A-7o("2-'et-, "`4'e1G-7 P�'�' ADDRESS �Ce`f./-7e-
CITY a7 eN A, c.�STATE ¢ ZIP d���f TEL�W'S '1-6 71 1
FAX / Er '�/ z "_�7�' EMAIL
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY F'INAI_,INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
// FEE: $ PERMIT
PLAN REVIEW NOTES