HomeMy WebLinkAboutBLDG-16-004595 `. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1
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1 JOBSITE ADDRESS ' 3 Cc"/ /--)47-(12 G, OWNER'S NAME 1%:"7 Cr/ ,.'r,
CF R IAN2 DRESS �`C- Tr-3- ?c! c FAX
TYPIE OR..... I
1P1tI1!' i;v� �C`rSttP NiC.`7F!E COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
'EA —= �I REGVATION: ❑ El------REPLACEMENT:�" PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE --
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE j
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UN'VENTED ROOM HEATER L I
WATER HEATER 1
OTHER '
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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 ❑ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY gl-------! 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 inn complianceco with all nent provi ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - '« f � '
PLUMBER-GASFITTER NAME LICENSE#55Ce SIGNATURE
MP❑ MGF❑ JP JGF❑ LPGI ❑ CORPORATION # PARTNERSHIP❑# LLC❑#
14_ -vim �� / ADDRESS 7'U- �C'—��
COMPANY NAME �U C"�C/ �/ i/ �
CITY �i c' �t' STATE PA-- ZIP CJ...2‘17 9.. TEL SOY Yf2'-‘7/ 7
SDI
FAX CELL 67.c- EMAIL
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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